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

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #15 provided on November 
14, 2022. 
 
You asked the Plan to pay more for the dental service. You say that the Plan promised to pay for the dental 
service. The Plan denied your request. The Plan says your annual maximum dental benefit for the year 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. On June 29, 
2022, the Plan paid $245 for dental services. On November 2, 2022, the Plan paid $310 for dental services. On 
November 14, 2022, the Plan paid $945 for dental services. For the year of 2022 the Plan paid a total of $1,500 
($245 paid + $310 paid + $945 paid) for dental services; therefore, your annual dental benefit for the year was 
exhausted on the date of service of November 14, 2022. Therefore, we decided that the Plan does not have to 
pay more for a crown (D2740) for tooth #15 provided on November 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mandibular partial denture (D5226), provided on 
November 8, 2022. 
 
You asked the Plan to pay for a mandibular partial denture. You say that you have a dental rider. You say this 
should be covered. The Plan denied your request. The Plan says D5226 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 a 
mandibular partial denture (D5226), provided on November 8, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a urology procedure provided on November 01, 2021. 
 
You asked the Plan to pay for a urology procedure. You say that this was medically necessary and should be 
covered. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a urology procedure 
provided on November 01, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on November 10, 2022. 
 
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 that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for laboratory services 
provided on November 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392/D2331) provided on 
November 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you had a limit on fillings. 
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 10, 2022. Therefore, 
we decided that the Plan does not have to pay for a resin-based composite (D2392/D2331) provided on 
November 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to increase the reimbursement for prophylaxis services provided on 
February 17, 2022, and August 17, 2022. 
 
You asked the Plan to increase the reimbursement for the prophylaxis services. You say that you disagree with 
the amount you were reimbursed for these services. The Plan denied your request. The Plan says you have been 
reimbursed the correct amount. 
 
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 were reimbursed the full Medicare allowed amount for the prophylaxis services. 
Therefore, we decided that the Plan does not have to increase the reimbursement for prophylaxis services 
provided on February 17, 2022, and August 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) and a panoramic x-ray (D0330) 
provided on November 11, 2022. 
 
You asked the Plan to pay for the consultation and x-ray. You say that you were told the panoramic x-ray 
would be covered. The Plan denied your request. The Plan says that a consultation (D9310) is not covered by 
your dental benefits. The Plan also says that your benefit for a panoramic x-ray 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, a consultation is not among those 
covered under this benefit. The record shows your benefit for a panoramic x-ray was exhausted on date of 
service November 11, 2021. Therefore, we decided that the Plan does not have to pay for a consultation 
(D9310) and a panoramic x-ray (D0330) provided on November 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation -  (D0180) provided 
on December 15, 2021. 
 
You asked the Plan to pay for the dental services. You say that you checked prior to receiving services and the 
provider was in-network. 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 comprehensive periodontal evaluation -  (D0180) provided on December 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 17, 
2022, to October 8, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you did not stay in a SNF for 21 days. 
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 $0 
copayment each day for days 1 to 20 and a $150 copayment each day for days 21 to 100 for each SNF 
admission.  
 
You have been asked to pay a $150 copayment for day 21 of a SNF stay. This item/service falls within the 
Skilled Nursing Facility 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 copayment for a SNF stay 
provided from September 17, 2022, to October 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740), and an extraction (D7210), provided on 
June 14, 2022, to June 29, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay 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, 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 crown (D2740), and an extraction (D7210), provided on June 14, 2022, to June 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing care provided on March 16, 2022, to 
April 07, 2022. 
 
You asked the Plan to pay for the subsequent nursing care. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the subsequent nursing 
care provided on March 16, 2022, to April 07, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the advanced care planning provided on October 26, 2022. 
 
You asked the Plan to pay for the advanced care planning. You say that the enrollee was in a nursing home and 
authorization could not be obtained due to the pandemic. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the advanced care 
planning provided on October 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility (SNF) visit provided on November 
28, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a SNF visit. You say that we depend upon the facility staff to verify eligibility 
and to obtain authorization from the patients insurance. 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 out-of-network (OON) 
provider or facility. 
 
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 skilled nursing facility (SNF) visit provided on 
November 28, 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 limited oral evaluation (D0140), cone beam imaging 
(D0364), and pulp vitality tests (D0460) provided on November 10, 2022. 
 
You asked the Plan to pay for the evaluation, imaging, and vitality tests. You say that these services should be 
covered as a medical condition. The Plan denied your request. The Plan says that cone beam imaging (D0364) 
and pulp vitality tests (D0460) are not covered by your dental benefits. The Plan also says that your benefit for 
a limited oral evaluation 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, cone beam imaging and pulp vitality 
tests are not among those covered under this benefit. The record shows your benefit for a limited oral 
evaluation was exhausted on date of service November 2, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), cone beam imaging (D0364), and pulp vitality tests (D0460) 
provided on November 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 13, 2022. 
 
You asked the Plan to pay for office visit. You say that these charges should be covered because your insurance 
has paid for them in the past. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for office visit provided on 
December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an extraction, erupted tooth requiring 
removal of bone (D7210). We also decided that the Plan does not have to pay for a bone replacement graft for 
ridge preservation - per site (D7953) provided on December 22, 2022. 
 
You asked the Plan to waive the coinsurance for the extraction erupted tooth requiring removal of bone 
(D7210). You also asked the Plan to pay for a bone replacement graft for ridge preservation - per site (D7953). 
You say that the bone graft was needed in order to receive the implant in the future. The Plan denied your 
request. The Plan says the coinsurance was appropriately applied to the extraction. The Plan says that the bone 
replacement graft for ridge preservation is not covered under the enrollees benefits. 
 
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 50% 
coinsurance for extractions provided out-of-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. 
 
You have been asked to pay a 50% coinsurance for the extraction. This service falls within the oral surgery 
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 an extraction, erupted tooth 
requiring removal of bone (D7210) provided on December 22, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the bone replacement graft for ridge 
preservation - per site (D7953) is not among those covered under this benefit. Therefore, we decided the Plan 
does not have to pay for the bone replacement graft for ridge preservation - per site (D7953) provided on 
December 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services provided on November 29, 
2022. 
 
You asked the Plan to waive the copayment for lab services. You say that you do not agree with the cost 
sharing applied to 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 $5 
copayment for in-network Medicare-covered lab services, per provider, per day. 
 
You have been asked to pay a $5 copayment for lab services. This item/service falls within the in-network 
Medicare-covered lab services, per provider, per day 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 lab services provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia (D9222) provided on August 26, 2021, to 
February 22, 2022. 
 
You asked the Plan to pay for anesthesia. You say that you believe these services should be covered. The Plan 
denied your request. The Plan says anesthesia 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 anesthesia 
(D9222) provided on August 26, 2021, to February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant removal and surgical placement of an implant body 
(D6100, D6010) provided on November 7, 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 implant 
removal and surgical placement of an implant body (D6100, D6010) provided on November 7, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician specialist services provided on November 29, 
2022. 
 
You asked the Plan to pay for physician specialist services. You say that you are appealing the claim payment 
denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physician specialist 
services provided on November 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Chiropractic manipulative treatment provided on August 22, 
2022, to August 25, 2022. 
 
You asked the Plan to pay for Chiropractic manipulative treatment. You say that you are appealing the claim 
payment denial. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for Chiropractic 
manipulative treatment provided on August 22, 2022, to August 25, 2022.