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

 
We decided that the Plan has to pay for the crown (D2750) and core buildup, including any pins when required 
(D2950) provided on January 6, 2022. 
 
You asked the Plan to pay for the crown and core buildup. You say that you were advised that these services 
were covered and now you are receiving a bill. The Plan denied your request. The Plan says that these services 
are not covered under the benefit 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. 
 
We looked at the file and Medicare rules. The 2022 Evidence of Coverage states crowns and core buildups are 
covered services. The contract does not state exactly what types of crowns and core buildups are covered, or 
excluded from coverage. You reasonably believed these services would be covered, as they are listed as 
covered services. Based on this information, we decided that the Plan's rules for coverage of the crown and 
core buildup have been met. Therefore, we decided that the Plan has to pay for the crown (D2750) and core 
buildup, including any pins when required (D2950) provided on January 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a resin-based composite filling (D2393) provided on March 15, 2022. 
 
You asked the Plan to pay for a filling. You say that you disagree with the denial of dental services. The Plan 
denied your request. The Plan says to consult your benefit documents for information about restrictions for this 
service. 
 
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 did not provide supporting documents that were used in making this 
decision. The Plan did not support their decision to deny your request. Therefore, we decided that the Plan has 
to pay for a resin-based composite filling (D2393) provided on March 15, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for out of network chiropractic care provided 
on June 23, 2021. 
 
You asked the Plan to waive the copayment for out of network chiropractic care. You say that you were told 
the provider was in network and if you would have known how much the copayment would be you wouldn't 
have gone. The Plan denied your request. The Plan says the copayment applied 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 $15 
copayment for each Medicare covered chiropractic visit.  
 
You have been asked to pay $15 copayment which is less than the standard $55 copayment for out of network 
chiropractic care. Chiropractic care falls within the Chiropractic 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 out of network chiropractic care provided on June 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve these dental items. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says your benefit for the requested items 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 Plan's 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 was exhausted on date of service December 23, 2020. The Plan 
contract states that coverage for partial dentures is limited to one per arch every five years. You previously 
received these dental items on December 23, 2020. Therefore, you have exhausted the allowable benefit. 
Therefore, we decided that the Plan does not have to pre-approve an upper partial denture (D5213) and a lower 
partial denture (D5214).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on February 10, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on February 10, 2022, by an 
out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a molecular pathology test provided on February 17, 2022, 
by an OON provider. 
 
You asked the Plan to pay for a molecular pathology test. You say that you are submitting medical records to 
support medical necessity. The Plan denied your request. The Plan says the out-of-network services were not 
authorized. 
 
 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 a molecular pathology test provided on February 
17, 2022, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for inpatient provider services provided 
February 21, 2022, to February 25, 2022. 
 
You asked the Plan to waive the coinsurance for inpatient provider services. You say that you were improperly 
billed for out-of-network services. The Plan denied your request. The Plan says the coinsurance was applied 
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 40% 
coinsurance for out-of-network Inpatient Hospital Care.  
 
 
 
 
 
 You have been asked to pay a $111.72 coinsurance for inpatient provider services. Inpatient provider services 
fall within the Inpatient Hospital Care 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 
inpatient provider services provided February 21, 2022, to February 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on January 21, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on January 21, 2022, by an 
out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital care and cardiac 
rehabilitation services provided from December 28, 2021, to January 31, 2022. 
 
You asked the Plan to waive the copayments for the inpatient care and cardiac rehab services. You say that you 
had a heart attack and the care was necessary. 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 $375 per 
day for days 1-5 and $0 per day after day 5 for each inpatient admission. 
 
Your contract with the Plan also clearly says that you must pay a $25 copayment for cardiac rehabilitation 
services. You have been asked to pay $375 per day for one day of inpatient care. The inpatient care falls within the 
Inpatient Hospital Care benefit category. You have also been asked to pay a $25 copayment for each of the four 
cardiac rehab services, for a total of $100. The cardiac rehab services fall within the Cardiac Rehabilitation 
Services benefit category. The total for all services is $475. 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 copayments 
for inpatient hospital care and cardiac rehabilitation services provided from December 28, 2021, to January 31, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) and the limited 
oral evaluation (D0140) provided on March 21, 2022. 
 
You asked the Plan to pay for these dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the services provided 
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 services provided has been exhausted. The Plan contract says that two oral exams 
are covered per calendar year. An oral exam was provided to you previously on February 1, 2022 and March 9, 
2022; therefore, you have exhausted the allowable benefit. Additionally, the Plan contract says that full mouth 
x-rays are covered once every five years.  
 You previously received a panoramic radiographic image on April 23, 2021; therefore, you have exhausted the 
allowable benefit for this service. Therefore, we decided that the Plan does not have to pay for the panoramic 
radiographic image (D0330) and the limited oral evaluation (D0140) provided on March 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on February 18, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on February 18, 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 periodic oral evaluation (D0120), bitewing x-rays 
(D0274), topical application of fluoride varnish (D1206), and periodontal maintenance (D4910) provided on 
April 19, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the dental services. You say that no communication was provided notifying your 
office that the treating provider was OON. The Plan denied your request. The Plan says services are only 
covered by the enrollee's Health Plan for in-network dentists. The Plan also says the records do not show that 
the treating dentist is in the Plan's provider network. 
 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the periodic 
oral evaluation (D0120), bitewing x-rays (D0274), topical application of fluoride varnish (D1206), and 
periodontal maintenance (D4910) provided on April 19, 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 internal bleachings (D9974) and endodontic therapies 
(D3310) provided on January 14, 2022. 
 
You asked the Plan to pay for the internal bleachings and endodontic therapies. You say that you expected 
these services to be covered as an in-network medical insurance claim. You also say that the teeth bleaching 
was in no way cosmetic out of vanity. The Plan denied your request. The Plan says the maximum 
reimbursement allotted for dental services in 2022 has been paid by the Plan. The Plan also says that cosmetic 
services are not covered. 
 
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 internal bleachings (D9974) are 
considered cosmetic services and are not among those covered under this benefit. The Plan offers up to $1,200 
every year for non-Medicare covered preventive and comprehensive dental services combined. You are 
responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit on February 1, 2022, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the internal bleachings (D9974) and endodontic therapies 
(D3310) provided on January 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 6, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
April 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service March 12, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says this claim is a duplicate of a previously paid claim and 
was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. The file includes evidence that the items/services at issue were 
reimbursed by the Plan on April 4, 2022. Comparison of the two claims shows these are exact duplicates. There 
is no evidence presented to support that the billed items/services were provided twice on the same date. Based 
on this information, we decided that the Medicare rules for procedure code 76641 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of service 
March 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. The Plan denied your 
request. The Plan says the Plan does not pay separately for this service. 
 
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 March 29, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
The record shows that you refused transportation. Therefore, we decided that the Plan does not have to pay for 
the ambulance response and treatment with no transport (A0998) provided on March 29, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transportation provided on 
November 23, 2021. 
 
You asked the Plan to waive the copayment for the ambulance transportation. You say that the charge is absurd 
to take you to a hospital 70 miles away. You say there is a hospital nearby. 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 
copayment for each one-way ambulance trip.  
 
You have been asked to pay $200, which is less than the $300 copayment 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 November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the core buildup, 
including any pins when required (D2950) provided on February 7, 2022. 
 
You asked the Plan to pay for these dental 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 covered 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 porcelain/ceramic 
crown (D2740) and the core buildup, including any pins when required (D2950) provided on February 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for dialysis services provided from February 
23, 2022, to March 7, 2022. 
 
You asked the Plan to waive the coinsurance for dialysis services. You say that you were told this would be 
covered in full. The Plan denied your request. The Plan says the coinsurance applied 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 20% 
coinsurance for outpatient dialysis services.  
 
You have been asked to pay $224 which is 20% of the allowed amount for dialysis services. The allowed 
amount is $1,184(20% x $1,184= $224). Dialysis services fall within the Services to Treat Kidney Disease 
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 dialysis services provided from 
February 23, 2022, to March 7, 2022.