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

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on March 10, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay more for the prophylaxis. You say that you have paid this charge in full and expect 
to be reimbursed. 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 OON 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 OON 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 the prophylaxis (D1110) provided on March 10, 2022, by an out-of-
network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for transportation provided on March 03, 2022. 
 
You asked the Plan to waive the copayment for transportation. You say that you had no other way to get to the 
hospital, so you feel you should not have to pay this bill. 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 a $150 
copayment for ambulance services. 
 
You have been asked to pay a $150 copayment for transportation. This item/service 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 transportation provided on 
March 03, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve radiation treatment and ultrasonic guidance. 
 
You asked the Plan to pre-approve radiation treatment and ultrasonic guidance. You say that the services are 
necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, 
coverage criteria have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 radiation treatment and ultrasonic 
guidance. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found certainly using ultrasound on a daily basis is not 
unreasonable to offer but not necessary. Therefore, to bill for daily simple simulations and/or image-guided 
radiation therapy (IGRT) for a technology for which need has not been established by published data or 
supported by consensus guidelines is not necessary. Billing for daily simulations (also requested in this case) or 
IGRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of radiation treatment and ultrasonic guidance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve radiation treatment and ultrasonic guidance.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the excision of hyperplastic tissue (D7970), the analgesia 
(D9230), and the panoramic x-ray (D0330) provided on June 17, 2022. 
 
You asked the Plan to pay for the excision of hyperplastic tissue (D7970), the analgesia (D9230), and the 
panoramic x-ray (D0330). You say that the procedure was for the removal of a salivary stone blocking a duct. 
You say you do not understand why it is not covered. The Plan denied your request. The Plan says the services 
are not covered benefits and your benefit for the panoramic x-ray (D0330) 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, the excision of hyperplastic tissue 
(D7970) and the analgesia (D9230) are not among those covered under this benefit. The record shows your 
benefit for the panoramic x-ray (D0330) was exhausted on date of service June 15, 2022. Therefore, we 
decided that the Plan does not have to pay for the excision of hyperplastic tissue (D7970), the analgesia 
(D9230), and the panoramic x-ray (D0330) provided on June 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), intraoral imaging 
(D0220), a crown (D2740), and a core build-up (D2950), provided by a participating provider on June 3, 2021, 
to June 7, 2021. 
 
You asked the Plan to pay for a limited oral evaluation, intraoral imaging, a crown, and a core build-up. You 
say that all these services were medically necessary for your crown. The Plan denied your request. The Plan 
says the rendered dental services are not covered 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 a limited oral evaluation (D0140), intraoral imaging (D0220), a crown (D2740), and a core build-up (D2950), provided 
by a participating provider on June 3, 2021, to June 7, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are having pain, swelling and some 
bleeding from the cracked tooth that was filled by the 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 requested item or service was exhausted on date of service May 24, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scaling in the presence of generalized moderate or severe 
gingival inflammation (D4346) and drugs or medicaments dispensed in the office for home use (D9630) 
provided on February 1, 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 scaling in the presence of generalized moderate or severe gingival 
inflammation (D4346) and drugs or medicaments dispensed in the office for home use (D9630) are not covered 
by your routine 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 scaling in 
the presence of generalized moderate or severe gingival inflammation (D4346) and drugs or medicaments 
dispensed in the office for home use (D9630) provided on February 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a full mouth debridement (D4355) provided by a 
participating provider on June 23, 2022. 
 
You asked the Plan to pay for a full mouth debridement. You say that this was your first cleaning. The Plan 
denied your request. The Plan says dental debridement is not a cleaning. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a full 
mouth debridement (D4355) provided by a participating provider on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth specialist visit provided on March 30, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for a telehealth specialist visit. You say that this should be covered. The Plan denied 
your request. The Plan says there was no preauthorization by a primary care provider (this is different than a 
referral) for an OON provider or facility, and this was not an emergency. Therefore, the decision is upheld. 
 
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 telehealth specialist visit provided on March 30, 
2022, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the non-emergency ambulance transportation (A0428) provided on March 24, 2022.

You asked the Plan to waive the copayment for the non-emergency transportation. You say that you feel this service should be covered because you were transported from a hospital to a skilled nursing facility. 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 a $125 copay for Ambulance services. 

You have been asked to pay a $125 copay for the non-emergency transportation. This item/service 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 the non-emergency ambulance transportation (A0428) provided on March 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), cone 
beam computed tomography (CT) capture and interpretation (D0364), pulp vitality tests (D0460), and pulpal 
debridement (D3221) provided on June 24, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluation, cone beam CT capture and 
interpretation, pulp vitality tests, and pulpal debridement. You say that you initially went in for a root canal 
which you thought would be partially covered, but then they realized one of your teeth had long cracks and 
they stopped the root canal. You also say that they advised the tooth would need to be extracted by an oral 
surgeon, and put a temporary filling in. The Plan denied your request. The Plan says these 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 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 
problem focused limited oral evaluation (D0140), cone beam computed tomography (CT) capture and 
interpretation (D0364), pulp vitality tests (D0460), and pulpal debridement (D3221) provided on June 24, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #19 (D2950) and the retreatment of a 
previous root canal on tooth #19 (D3348) provided on June 10, 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 core build up (D2950) and the retreatment of a previous root canal 
(D3348) are not covered by your supplemental 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 core build 
up on tooth #19 (D2950) and the retreatment of a previous root canal on tooth #19 (D3348) provided on June 
10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration to 
confirm what your responsibility for the services would be. 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 June 20, 2022. Therefore, 
we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
June 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral imaging (D0220 and D0230) provided by a 
participating provider on March 23, 2022. 
 
You asked the Plan to pay for intraoral imaging. You say that you told the provider you only wanted the 
services that were covered. The Plan denied your request. The Plan says the rendered dental 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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for intraoral 
imaging (D0220 and D0230) provided by a participating provider on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and an intraoral image 
(D0220) provided by an out-of-network provider on June 6, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency, and your dentist was on 
vacation. You say that you should not be charged for this. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, D0220 is not covered under this benefit when received from an out-of-network provider. D0140 is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for a limited oral evaluation (D0140) and an intraoral image (D0220) provided by an out-of-
network provider on June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic on tooth #3 (D6245) and prefabricated post and core 
on tooth #3 (D2954) provided on July 6, 2022. 
 
You asked the Plan to pay for a pontic and a prefabricated post. You say that you disagree with the denial of 
dental services. The Plan denied your request. The Plan says a pontic (D6245) and prefabricated post and core 
(D2954) are not covered by the enrollee's supplemental 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 a pontic 
on tooth #3 (D6245) and prefabricated post and core on tooth #3 (D2954) provided on July 6, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency ambulance transportation (A0429) and 
ground mileage (A0425) provided on September 21, 2020. 
 
You asked the Plan to pay for the emergency ambulance transportation and ground mileage. You say that you 
would like this claim to be reprocessed for payment. The Plan denied your request. The Plan says this claim 
was received on April 27, 2022, which is past the allowed 12-month timeframe. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the emergency ambulance transportation and ground mileage was not filed 
until April 27, 2022. This means that more than one calendar year from the date of service had passed before a 
claim was filed. Therefore, we decided that the Plan does not have to pay for the emergency ambulance 
transportation (A0429) and ground mileage (A0425) provided on September 21, 2020.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the insulin injections (J1815) and self-administered drugs 
(A9270) provided from December 17, 2021, to December 20, 2021. 
 
You asked the Plan to pay for the insulin injections and self-administered drugs. You say that you would like 
this claim to be reprocessed. The Plan denied your request. The Plan says self-administered drugs, including 
insulin injections, are not covered.  
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the insulin injections (J1815) and 
self-administered drugs (A9270) provided from December 17, 2021, to December 20, 2021.  
 
Benefits for the insulin injections and self-administered drugs may be available under Medicare Part D. Contact 
the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 1, 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 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 May 17, 2022. Therefore, 
we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on July 1, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the destruction of benign lesions and 
dermatology office visit provided on June 20, 2022. 
 
You asked the Plan to waive the copayment for destruction of benign lesions and outpatient office visit. You 
say that you feel as though you should not have to pay this bill. 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 a $35 
copayment for a specialist office visit, and a $750 deductible for services including outpatient surgery, 
including services provided at hospital outpatient facilities and ambulatory surgical centers. 
 
You have been asked to pay a $35 copayment for a dermatology office visit. This item/service falls within the 
specialist visit benefit category, you have been asked to pay a $110.85 deductible for the destruction of benign 
lesions. Your annual deductible amount is $750. At the time of service, you had met $229.84 of the $750 
deductible. The total amount you are being asked to pay is $145.85 ($35 + $110.85 = $145.85). 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 destruction of benign lesions and outpatient office visit provided 
on June 20, 2022.