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

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for 
tooth #20. 
 
You asked the Plan to pre-approve a porcelain and high noble metal crown. You say that this service is 
necessary, and you understand that crowns are covered by the enrollee's dental benefit. The Plan denied your 
request. The Plan says this specific type of crown is not covered by the enrollee's 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the specific crown requested, porcelain 
fused to high noble metal (D2750) is not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pre-approve a porcelain fused to high noble metal crown (D2750) for tooth #20.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound supplies provided on March 15, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the wound supplies. You say that these supplies are separately billable and do not 
require separate authorization. The Plan denied your request. The Plan says the services were provided out-of-
network and were not approved in advance. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the wound supplies provided on March 15, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the second filling (D2392) provided February 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only had one filling done. 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 same date of service, February 7, 
2022. Therefore, we decided that the Plan does not have to pay for the second filling (D2392) provided 
February 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physician's services for a second opinion to be provided 
by the requested out-of-network provider. 
 
You asked the Plan to pre-approve physician's services for a second opinion to be provided by the requested 
out-of-network provider. You say that you would like to get more information regarding any other treatment 
options that you have for your stage 4 metastatic prostate cancer. The Plan denied your request. The Plan says 
the Plan will not authorize medically necessary care outside the health Plan network unless that care is not 
available within the network. In this case, there are many oncologists in the network and therefore, you can 
receive the care you need within the health Plan 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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve 
physician's services for a second opinion to be provided by the requested out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond crown (D2920) provided on March 
31, 2022. 
 
You asked the Plan to pay for the re-cement or re-bond crown. You say that prior to this appointment, you 
contacted the Plan and were advised that the treating provider was covered under your plan. You also say that 
you were told if you saw an out-of-network provider, a portion would still be covered. The Plan denied your 
request. The Plan says this service is not a covered expense 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 re-
cement or re-bond crown (D2920) provided on March 31, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on July 
1, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that you tested positive 
for COVID-19 and went to the hospital. You say the staff was not helpful. The Plan denied your request. The 
Plan says you have been charged the correct cost sharing 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 $300 
for each one-way ambulance trip.  
 
You have been asked to pay a $300 for the ambulance transportation. The ambulance transportation falls within 
the Ambulance Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for ambulance 
transportation provided on July 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), 
panoramic x-ray (D0330), removal of impacted tooth (D7220), and collection and application of autologous 
blood concentrate product (D7921) provided on February 14, 2022. 
 
  You asked the Plan to pay for the problem focused limited oral evaluation, panoramic x-ray, removal of 
impacted tooth, and collection and application of autologous blood concentrate product. You say that you 
contacted the Plan and were told the tooth extraction would be covered. You also say that you cannot afford to 
pay for these services. The Plan denied your request. The Plan says the problem focused limited oral evaluation 
and panoramic x-ray exceed the frequency limitations in your benefit plan. The Plan also says that the removal 
of impacted tooth and collection and application of autologous blood concentrate product are not covered 
benefits 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 removal of impacted tooth and 
collection and application of autologous blood concentrate product are not among those covered under this 
benefit. The contract says problem focused limited oral evaluation (D0140) is limited to one procedure per plan 
year, and panoramic x-ray (D0330) is limited to one procedure every three plan years. The record shows that 
you received a problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) on January 3, 
2022, and your problem focused limited oral evaluation (D0140) and panoramic x-ray (D0330) benefits have 
been exhausted. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral 
evaluation (D0140), panoramic x-ray (D0330), removal of impacted tooth (D7220), and collection and 
application of autologous blood concentrate product (D7921) provided on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interim partial denture for the upper jaw (D5820) 
provided on February 10, 2022. 
 
You asked the Plan to pay for the interim denture. You say that this service was necessary, and you cannot 
afford this cost. The Plan denied your request. The Plan says this service is not covered by your 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. 
 
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 
interim partial denture for the upper jaw (D5820) provided on February 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial dentures (D5213) and mandibular 
partial dentures (D5214). 
 
You asked the Plan to pre-approve the partial dentures. You say that you need dentures and would like to have 
them covered. The Plan denied your request. The Plan says maxillary partial dentures (D5213) and mandibular 
partial dentures (D5214) are not covered by 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 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 pre-approve 
maxillary partial dentures (D5213) and mandibular partial dentures (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 8, 2022. 
 
You asked the Plan to pay for the dental service. You say that you went to your general dentist for dental 
issues. You say that you were referred to the endodontist to see if you needed a root canal. You also say that 
you do not understand why one provider was paid but the other was denied. The Plan denied your request. The 
Plan says one limited oral evaluation is covered per plan year. The Plan also says that the frequency limit has 
been exceeded. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, 
there is a limit of one per plan year. The record shows that the Plan paid for a limited oral evaluation that you 
received on March 9, 2022. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation (D0140) provided on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), periapical x-
ray (D0220), bitewing x-ray (D0274), prophylaxis (D1110), and topical application of fluoride (D1208) 
provided on March 7, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you disagree with the amount paid by the 
insurance company. 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 a comprehensive oral evaluation (D0150), 
periapical x-ray (D0220), bitewing x-ray (D0274), prophylaxis (D1110), and topical application of fluoride 
(D1208) provided on March 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve three gingivectomies or gingivoplasties (D4212 x3). 
 
You asked the Plan to pre-approve the gingivectomies or gingivoplasties. You say that you need this work done 
on three teeth so you can eat. The Plan denied your request. The Plan says this service is not covered under 
your benefit package. 
 
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 pre-approve three gingivectomies or gingivoplasties 
(D4212 x3).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental occlusal guard (D9944). 
 
You asked the Plan to pre-approve a dental guard. You say that this mouth guard is medically necessary to 
protect your teeth from further wear due to grinding. The Plan denied your request. The Plan says this service is 
not covered by your 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. 
 
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 a 
dental occlusal guard (D9944).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a light-emitting diode (LED) light package. 
 
You asked the Plan to pre-approve an LED light package. You say that this should be covered. The Plan denied 
your request. The Plan says this does not serve a medical purpose. 
 
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 light-emitting diode (LED) light package.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient hospital visit on March 17, 2022. 
 
You asked the Plan to waive the copayment for outpatient hospital visit. You say that you want to appeal the 
amount being charged. The Plan denied your request. The Plan says the cost-sharing you are being charged is 
correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $325 
copayment for each Medicare-covered outpatient hospital visit or hospital outpatient surgical facility visit. The 
provider billed in the amount of $190 and the allowed amount is $136.49, which is less than the copayment 
amount. Therefore, results in the total cost-sharing amount of $136.49.  
 
 
 
 
 You have been asked to pay a $136.49 copayment, which is less than the copayment for outpatient hospital 
visit. Outpatient hospital visits fall within the Outpatient surgery, including services provided at hospital 
outpatient facilities and ambulatory surgical centers benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for outpatient hospital visit on March 17, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an eye ultrasound provided on October 23, 
2021. 
 
You asked the Plan to waive the copayment for an eye ultrasound. You say that the billing code is incorrect and 
that you did not have an ultrasound. The Plan denied your request. The Plan says the copayment applied was 
correct. 
 
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 $100 
copayment for outpatient diagnostic tests and therapeutic services and supplies.  
 
You have been asked to pay the allowed amount of $79.12 which is less than the $100 copayment for an eye 
ultrasound. An eye ultrasound falls within the Outpatient Diagnostic Tests and Therapeutic Services and 
Supplies benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan.  This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to waive the copayment for an eye ultrasound provided on October 23, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (dental code D2330), a resin-based 
composite (dental code D2332), a crown (dental code D2740), an addition to crown (dental code D2954), and 
endodontic therapy (dental code D3310) for tooth #22, #23, #24, #25, #26, and #27 provided on August 17, 
2021, and September 1, 2021. 
 
You asked the Plan to pay for a resin-based composite, a crown, an addition to crown, and endodontic therapy. 
You say that the dental service was initially approved but you could not make the date of service. The Plan 
denied your request. The Plan says the denial for these services is correct, because they are not covered by the 
Plan. Also, the enrollee's plan was terminated on the last day of May of 2021. 
 
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 a resin-
based composite (dental code D2330), a resin-based composite (dental code D2332), a crown (dental code 
D2740), an addition to crown (dental code D2954), and endodontic therapy (dental code D3310) for tooth #22, 
#23, #24, #25, #26, and #27 provided on August 17, 2021, and September 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by the requested out-of-
network provider. 
 
You asked the Plan to pre-approve an office visit to be provided by the requested out-of-network provider. You 
say that you have anxiety and elevated blood pressure and this is the only dentist you are comfortable seeing. 
The Plan denied your request. The Plan says you must use network providers to get medical care and services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office 
visit to be provided by the requested out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for laboratory services and Part B drugs 
provided on January 26, 2022. 
 
You asked the Plan to waive the cost share for laboratory services and Part B drugs. You say that you never 
had to pay this much before for the services. The Plan denied your request. The Plan says the cost share applied 
is correct. 
 
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 $500 deductible which applies to Medicare Part B drugs and lab 
services and a 5% coinsurance for each Medicare covered chemotherapy drug.  
 
 
 
 
 The item or service you asked the Plan to waive the cost share for falls within the benefit category Medicare 
Part B Prescription Drugs. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is $500 deductible which applies to Medicare Part B drugs and lab services. This cost sharing is a contractual 
obligation that had not been met at the time laboratory services and Part B drugs was received on January 26, 
2022. Therefore, $500 has been applied to meet the deductible. 
 
Since the $500 deductible was met, you have also been asked to pay $136.48 coinsurance for Part B drugs. 
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 the 
Plan does not have to waive the cost for laboratory services and Part B drugs provided on January 26, 2022.