Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) and annual alcohol misuse screening 
(G0442) provided on June 8, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you did not have this screening. You also 
say that you were seen for a shoulder injury. The Plan denied your request. The Plan says the frequency limit 
for this service has been exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that alcohol screening is non-covered when 
performed more than one time in a 12-month period. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient services have not been met. Therefore, we decided that the Plan does not have to pay 
for the office visit (99214) and annual alcohol misuse screening (G0442) provided on June 8, 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 July 8, 2022. 
 
You asked the Plan to pay for an evaluation. You say that this service was medically necessary. The Plan 
denied your request. The Plan says a limited oral evaluation (D0140) is 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 a limited 
oral evaluation (D0140) provided on July 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. 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 laboratory services provided on May 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit provided on May 24, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary or rest home 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 domiciliary or rest home visit provided on May 
24, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the crown repair. We decided that the Plan does not have to pay for the 
CT scan.  
 
You asked the Plan to pay for a cone beam CT scan of both jaws (D0367) and re-cementing or re-bonding of a 
crown (D2920) provided on May 11, 2022. You say that you feel it was necessary to have the crown re-
cemented when it popped off. You say you could not wait the 6 or 7 months until you became eligible again. 
The Plan says that the crown repair is only covered once every 24 months. The Plan also says that the last 
crown repair service was received on December 30, 2020, therefore, you would not be eligible until December 
30, 2022. 
 
 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 EOC submitted by the Plan does not say the crown repair service is covered 
once every 24 months. Rather, the contract does say the service is covered for two teeth per year. This is an 
administrative overturn based on the Plan providing incorrect contract information. 
 
We decided that the Plan must pay for the crown repair due to an issue with the contract submitted. We also 
decided that the Plan is not required to pay for the CT scan, as this is never a covered dental benefit. 
 
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: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal orthotic device (D7880) provided by a 
participating provider on March 14, 2022. 
 
You asked the Plan to pay for an occlusal orthotic device. You say that this should be covered. You say that 
this guard has unlocked your jaw. The Plan denied your request. The Plan says the rendered dental work 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 an 
occlusal orthotic device (D7880) provided by a participating provider on March 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three retainer crowns provided by a participating provider on 
October 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 maximum dental allowance amount was fully exhausted on date of service October 21, 2021. 
Therefore, we decided that the Plan does not have to pay for three retainer crowns provided by a participating 
provider on October 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated abutment on tooth #19 (D6056) and an 
abutment supported crown on tooth #19 (D6059) provided on March 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told since the dental work started last 
year these services would be covered. The Plan denied your request. The Plan says a prefabricated abutment 
(D6056) and an abutment supported crown (D6059) 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 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 
prefabricated abutment on tooth #19 (D6056) and an abutment supported crown on tooth #19 (D6059) provided 
on March 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay to reline a maxillary denture (D5750) provided on April 1, 2022. 
 
You asked the Plan to pay to the dental services. You say that you are being double billed for 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. 
 
The record shows you received this service on April 1, 2022. 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 March 30, 2022. Therefore, we decided that the Plan does not have to 
pay to reline a maxillary denture (D5750) provided on April 1, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Part B drugs on January 15, 2020.

You asked the Plan to waive the coinsurance for Part B drugs. You say that you want to appeal the amount
being charged. 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 20%
coinsurance for Medicare-covered Part B Chemotherapy drugs and other Part B drugs. These drugs are covered
under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan.
Covered drugs include drugs that usually aren't selfadministered by the patient and are injected or infused
while you are getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed
in the amount of $41,299.35 and the allowed amount is $11,514.26. $11,514.26 x 20% = $2,302.85. Therefore,
results in the total cost sharing amount of $2,302.85.

You have been asked to pay a 20% coinsurance for Part B drugs. This item/service falls within the Medicare
Part B prescription drugs 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 Part B
drugs on January 15, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic dental x-rays (code D0330) you received on June 
14, 2022. 
 
You asked the Plan to pay for the dental x-rays. You say that you were establishing yourself as a new patient 
with a new dentist, so these x-rays should be covered. The Plan denied your request. The Plan says your benefit 
for the x-rays 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. 
Your contract with the Plan limits coverage of panoramic dental x-rays to one procedure every three years. The 
record shows already received covered panoramic x-rays on December 14, 2021. Therefore, we decided that 
the Plan does not have to pay for panoramic dental x-rays (code D0330) you received on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (code D0367) you received on May 9, 2022. 
 
You asked the Plan to pay for code D0367. You say that you called and were advised that this visit would be 
covered. The Plan denied your request. The Plan says this service is not covered under your dental benefits.  
When you called to ask about coverage, you only asked if an evaluation would be covered.  You never asked 
about coverage for this specific cone beam service. 
 
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 cone 
beam computed tomography (CT) capture and interpretation (code D0367) you received on May 9, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a voice prosthesis, chest x-ray, and speech 
therapy provided on May 9, 2022. 
 
You asked the Plan to waive the cost share for a voice prosthesis, chest x-ray, and speech therapy. You say that 
you did not receive these services. 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 20% 
coinsurance for Medicare-covered equipment and supplies, a $35 copayment for x-rays and a $40 copayment 
for speech therapy.  
 
You have been asked to pay $23.09 for the voice prosthesis, a $35 copayment for the chest x-ray, and a $40 
copayment for speech therapy. The total amount you owe is $98.09 ($23.09 + $35 + $40 = $98.09). A voice 
prosthesis falls within the durable medical equipment (DME) and related supplies benefit category. Chest x-
rays fall within the outpatient diagnostic tests and therapeutic services benefit category. Speech therapy falls 
within the outpatient rehabilitation 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 cost share 
for a voice prosthesis, chest x-ray, and speech therapy provided on May 9, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a venogram and an embolization to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the venogram and an embolization. You say that there are no in-network 
providers that can treat the enrollee. The Plan denied your request. The Plan says the requested provider is an 
OON provider, and it was confirmed with an in-network provider that they can treat the enrollee. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
  The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a venogram and an embolization to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on July 19, 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 July 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 a cone beam CT capture (D0366) and a diagnostic service 
consultation (D9310) provided by an out-of-network provider on February 16, 2022. 
 
You asked the Plan to pay for a cone beam CT capture and a diagnostic service consultation. You say that all 
these services are necessary for a correct diagnosis and plan of action. 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 cone 
beam CT capture (D0366) and a diagnostic service consultation (D9310) provided by an out-of-network 
provider on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the maxillary partial denture - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) 
provided May 6, 2022. 
 
You asked the Plan to provide additional payment for the upper partial denture. You say that you are not happy 
with your dentures. The Plan denied your request. The Plan says this claim has processed correctly. The Plan 
also encourages you to work with the provider to correct the dentures as necessary. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the upper 
partial denture once every five calendar years up to the $1,000 annual maximum.  
 We looked at the file and Medicare rules. The Plan provided documentation showing that the partial denture 
was covered up to your $1,000 annual maximum. This means the claim has processed correctly and no further 
reimbursement is due. Therefore, we decided that the Plan does not have to provide additional payment for the 
maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping 
materials, rests and teeth) (D5213) provided May 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the two problem focused limited oral evaluations (D0140 
x2), first intraoral periapical x-ray (D0220), and re-cement or re-bond crown (D2920) provided on June 14, 
2022, and June 15, 2022. 
 
You asked the Plan to pay for the problem focused limited oral evaluations, first intraoral periapical x-ray, and 
re-cement or re-bond crown. You say that you would like these services to be covered by the Plan. The Plan 
denied your request. The Plan says these services are not covered expenses under your dental plan. The Plan 
also says that you contacted the Plan prior to the date of service, but only called to confirm participating status 
of provider and no benefit information was discussed. 
 
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 two 
problem focused limited oral evaluations (D0140 x2), first intraoral periapical x-ray (D0220), and re-cement or 
re-bond crown (D2920) provided on June 14, 2022, and June 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT capture (D0366) and the retreatment of a 
previous root canal therapy (D3348) provided by a participating provider on March 24, 2022, to March 31, 
2022. 
 
You asked the Plan to pay for a cone beam CT capture and the retreatment of a previous root canal therapy. 
You say that you are being overcharged. 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 cone 
beam CT capture (D0366) and the retreatment of a previous root canal therapy (D3348) provided by a 
participating provider on March 24, 2022, to March 31, 2022.