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

 
We decided that the Plan does not have to pay for a limited oral evaluation and intraoral x-ray (D0220, D0140, 
D0230) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 limited 
oral evaluation and intraoral x-ray (D0220, D0140, D0230) provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an intra oral x-ray and crown (D0220, 
D2751) provided on June 7, 2022. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. 
 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.    
 
You have been asked to pay a 50% coinsurance for dental services. This item/service falls within the dental 
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 an intra oral x-ray and crown 
(D0220, D2751) provided on June 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingival irrigation, oral medications, and cleaning (D4346, 
D9630, D4921) provided on July 8, 2022. 
 
You asked the Plan to pay for the gingival irrigation, oral medications, and cleaning. You say that the services 
should be covered as you disagree with the denial. The Plan denied your request. The Plan says the services 
denied correctly as they do not fall within 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 gingival 
irrigation, oral medications, and cleaning (D4346, D9630, D4921) provided on July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise classes purchased from January 10, 2022, to 
May 2, 2022. 
 
You asked the Plan to pay for the exercise classes. You say that you submitted proof of payment for classes for 
$175, but are only requesting to be reimbursed $150. You also say these classes are beneficial for your balance. 
The Plan denied your request. The Plan says no additional valid proof of payment was received by the Plan to 
show proof of the $25 paid for an eligible exercise class, qualified health club, or fitness facility. The Plan also 
says that you were approved and reimbursed $125 of the $150 as you provided valid proof of payment for yoga 
classes you attended. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers gym benefits 
only a reimbursement form along with proof of payment are submitted. 
 
 
  The Plans rules for coverage of gym benefits have not been met because valid proof of payment was not 
submitted for the services. Therefore, we decided that the Plan does not have to pay for the exercise classes 
purchased from January 10, 2022, to May 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) x2 
provided on July 18, 2022. 
 
You asked the Plan to pay for dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says this service is not covered under your 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. Core buildup, including any 
pins when required (D2950) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested core buildup, including 
any pins when required (D2950) x2are not among those covered under this benefit. Therefore, we decided that 
the Plan does not have to pay for core buildup, including any pins when required (D2950) x2 provided on July 
18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on August 22, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the visit was not a regular visit and should be 
covered under an emergency visit. 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 date of service of January 28, 2022. 
Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on 
August 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown, tooth extraction, and core buildup services (D2950, 
D6750, D7210, D9230) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 crown, 
tooth extraction, and core buildup services (D2950, D6750, D7210, D9230) provided on August 4, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says these 
services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on November 6, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you need additional 
rides above the 24 one-way rides because you are doing physical therapy, have 6 visits left, and future dental 
services to go to. The Plan denied your request. The Plan says your request for rides in addition to the 24 one-
way rides you are covered for exceeds the benefit limit. The Plan also says there are no exceptions that allow 
additional trips to be covered. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 24 one-way trips per year.   
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the treatment of root canal obstruction (D3331) for tooth #2 
provided on July 21, 2022. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure is a common procedure, and 
you would like the Plan to change the policy. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the treatment of root canal obstruction is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
treatment of root canal obstruction (D3331) for tooth #2 provided on July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gingivectomy (D4212) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says 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, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a gingivectomy (D4212) provided on May 3, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer. 
 
You asked the Plan to pre-approve Injectafer. You say that the requested Injectafer is medically necessary. The 
Plan denied your request. The Plan says the enrollee must try and fail Infed and Venofer first. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 Injectafer. Our reviewer says that the 
Plan's step therapy criteria have not been met. Our physician reviewer found based on the medical records 
provided there is no indication that the enrollee has tried and failed the required drug(s). Based on the medical 
records provided and the Medicare-approved major drug compendia there is no indication that the Plan's 
required drug(s) would likely be less effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Injectafer have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Injectafer.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services (D1354) provided on August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within 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 dental 
services (D1354) provided on August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Intracept procedure. 
 
You asked the Plan to pre-approve Intracept procedure. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 Intracept procedure. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee has a history of low back pain beginning 6-12 months ago. The Intracept 
procedure is experimental. More research is needed. Therefore, the enrollee does not meet criteria for the 
requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Intracept procedure have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Intracept procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a plastic eye prosthesis (V2623) to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a plastic eye prosthesis. You say that you require this procedure and have 
been with the provider for 40 years. The Plan denied your request. The Plan says the facility, service provider, 
or physician you are requesting the service with is not contracted with the Plan. The Plan also says the service, 
procedure, or evaluation may be offered by an in-network provider. 
 
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 plastic eye prosthesis (V2623) to be provided 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 bitewing x-rays (D0272) provided on August 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this procedure was needed to determine if there 
was an underlying cause for your pain. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 4, 2022. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0272) provided on August 
19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation. 
 
You asked the Plan to pre-approve additional non-emergency transportation. You say that you would like to 
appeal the Plan's denial for additional transportation. The Plan denied your request. The Plan says your request 
for rides in addition to the 48 one-way rides you are covered for exceeds the benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional non-emergency transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (codes V5267 and V5298) and hearing 
service (V5299) provided on July 20, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids and hearing service. You say that when you contacted the Plan, 
you were not advised that you had to go to an in-network provider. The Plan denied your request. The Plan 
says you received these services from an OON provider. The Plan also says hearing aids are offered as an 
additional benefit; however, the hearing aids must be ordered through the Plan's approved hearing aid vendor. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased through the Plan's approved hearing aid vendor.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids and hearing service have not been met. Therefore, we decided that the Plan does 
not have to pay for the hearing aids (codes V5267 and V5298) and hearing service (V5299) provided on July 
20, 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 dental services on August 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on August 15, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 29580 billed for date of service May 24, 
2022. 
 
You asked the Plan to pay for procedure code 29580. You say that this should be paid for. The Plan denied 
your request. The Plan says the number of units billed exceeds the maximum allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.   
In this case, the MUE for CPT code 29580 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 29580 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29580 billed for date of service May 24, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services. 
 
You asked the Plan to pay for the ambulance services. You say that you thought by declining the transport you 
would save the Plan and yourself from costs or unnecessary medical care. The Plan denied your request. The 
Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 30, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal of residual tooth roots (D7250) for tooth #14 and 
#15 provided on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that it was medically necessary for you to get the 
dental procedures done. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the removal of residual tooth roots is not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
removal of residual tooth roots (D7250) for tooth #14 and #15 provided on August 23, 2022.