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

 
We decided that the Plan does not have to pre-approve core buildup (D2950) for tooth #14. 
 
You asked the Plan to pre-approve core buildup. You say that the service is medically necessary The Plan 
denied your request. The Plan says that there is no clinical evidence to support medical necessity. 
 
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 core buildup 
when the services are medically necessary and reasonable.  
 
 
  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 core buildup. Our reviewer says that the 
supplied documentation does not support the need for a core buildup for tooth #14. The provided x-rays show 
an essentially intact #14 with likely distal decay. The amount of damaged tooth structure would be less than 
30% of the tooth and could be reasonably restored with a conventional material. In this case, there would be at 
least 70% of the structure remaining even if a crown was indicated, and a core buildup would not be necessary.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of core buildup have not been met. Therefore, we decided that the Plan does not 
have to pre-approve core buildup (D2950) for tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography capture and 
interpretation (D0364), and pulp vitality tests (D0460) provided on May 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the services at issue 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 computed tomography capture and interpretation (D0364), and pulp vitality tests (D0460) provided on 
May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic exam (code D0120) and prophylaxisadult (code 
D1110) provided on April 16, 2022. 
 
You asked the Plan to pay for the dental services. 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 periodic exam (code D0120) and prophylaxisadult (code D1110) provided on April 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital care provided on May 
27, 2022, to June 01, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care. You say that you were transferred to 
this facility since the previous facility could not render appropriate care. 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 $1,800 
copayment for inpatient hospital care. 
 
You have been asked to pay a $1,800 copayment for the inpatient hospital care. This item/service falls within 
the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Please note the transfer to a separate facility is considered a new admission. Per the EOC, 
there is a $360 copayment per day for days 1-5 of inpatient care. Your stay was for 5 days, for a total of $1,800. 
Therefore, we decided that the Plan does not have to waive the copayment for the inpatient hospital care 
provided on May 27, 2022, to June 01, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that this was part of your annual 
mammogram. 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 $98.58 
copayment for diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT 
scan. 
 
You have been asked to pay a $98.58 copayment for the breast ultrasound. This item/service falls within the 
diagnostic radiology services, such as ultrasound, nuclear cardiac imaging, PET, MRI, and CT scan 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. Please note that a 
breast ultrasound is an additional test not part of the mammogram. The allowed amount for the ultrasound is 
$98.58. Since this amount is less than the $100 copayment per the EOC, you are only responsible for the lesser amount. Therefore, we decided that the Plan does not have to waive the copayment for the breast ultrasound 
provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on June 
13, 2022. 
 
You asked the Plan to pay for the comprehensive oral evaluation. You say that a Plan representative referred 
you to a dentist, but the provider states they are not in-network with the Plan. 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 14, 2022. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) 
provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay for the surgical extraction (D7210). We decided that the Plan does not have 
to pay for the bone replacement graft for of the first site in quadrant (D4263), bone replacement graft for ridge 
preservation (D7953), and unspecified adjunctive procedures (D9999).  
 
You asked the Plan to pay for the surgical extraction (D7210), bone replacement graft for of the first site in 
quadrant (D4263), bone replacement graft for ridge preservation (D7953), and unspecified adjunctive 
procedures (D9999) provided from October 29, 2021, to July 6, 2022. You say that you would like to be 
reimbursed for these services. The Plan says that these services are not covered by the Plan. 
 
We decided that the Plan has to pay for the surgical extraction (D7210).  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
We looked at the file and Medicare rules. Specifically, the 2021 Evidence of Coverage lists extraction as a 
covered benefit. There are no limitations or exclusions provided in the contract pertaining to extractions. You 
reasonably believed the extraction you received would be covered because it is listed as a covered service in 
your 2021 Evidence of Coverage. Based on this information, we decided that the Plan's rules for coverage of 
the surgical extraction (D7210) have been met. Therefore, we decided that the Plan has to pay for the surgical 
extraction (D7210).  
 
We also decided that the Plan does not have to pay for the bone replacement graft for of the first site in 
quadrant (D4263), bone replacement graft for ridge preservation (D7953), and unspecified adjunctive 
procedures (D9999). 
 
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 bone 
replacement graft for of the first site in quadrant (D4263), bone replacement graft for ridge preservation 
(D7953), and unspecified adjunctive procedures (D9999). 
 
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 the panoramic x-ray (D0330), the bitewing x-rays (D0274), 
the comprehensive oral evaluation (D0150), and the cleaning (D1110) provided by an out-of-network provider 
on June 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that the Plan representative stated that the dentist 
was in-network and close to your home. 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 the panoramic x-ray (D0330), the bitewing x-rays (D0274), the comprehensive oral evaluation 
(D0150), and the cleaning (D1110) provided by an out-of-network provider on June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the outpatient hospital observation services 
provided on February 10, 2022. 
 
You asked the Plan to reduce the copayment for the outpatient hospital observation services. You say that you 
feel you should only have to pay the $90 ER copayment. 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 $275 
copayment for outpatient hospital observation. 
 
You have been asked to pay a $275 copayment for the outpatient hospital observation services. This 
item/service falls within the outpatient hospital observation 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. Please note that the ER copayment of $90 was 
waived due to staying under observation status. Therefore, we decided that the Plan does not have to reduce the 
copayment for the outpatient hospital observation services provided on February 10, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the computed tomography (CT) scan of the 
abdomen and pelvis provided on July 07, 2022. 
 
You asked the Plan to waive the copayment for the computed tomography (CT) scan of the abdomen and 
pelvis. You say that you were not informed of any costs for the service. 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 $175 
copayment for diagnostic imaging (CT scan). 
 
You have been asked to pay a $175 copayment for the computed tomography (CT) scan of the abdomen and 
pelvis. This item/service falls within the diagnostic imaging (CT scan) 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 computed tomography (CT) scan of the abdomen and pelvis 
provided on July 07, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 14302 billed for date of service November 10, 2021. 
 
You asked the Plan to pay for code 14302. You say that you submitted this claim in good faith and the services 
should be covered. The Plan denied your request. The Plan says this is an add-on code and the primary code 
billed is not eligible for payment. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 14302 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for code 14302 billed for date of service November 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
March 10, 2022. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you already paid 
your office visit copayment, and this should be included. 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 $10.46 
copayment for non-radiological diagnostic services (EKG). 
 
You have been asked to pay a $10.46 copayment for the electrocardiogram (EKG). This item/service falls 
within the non-radiological diagnostic services (EKG) 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. The allowed amount for the EKG is $10.46. Since this 
amount is less than the $40 copayment per the EOC, you are only responsible for the lesser amount. Therefore, 
we decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
March 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on June 8, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says there was no documentation 
found in the submitted records to indicate concern for acute on chronic CHF symptoms. 
 
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 inpatient hospital services provided on June 8, 
2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the nursing care services provided to the enrollee on March 16, 2022. 
 
You asked the Plan to pay for the nursing care. You say that the services were medically necessary. The Plan 
denied your request. The Plan says that coverage was denied due to having no prior authorization for out-of-
network care. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan has out-of-network benefits, and authorization is not required. It is the 
burden of the Health Plan to substantiate their denial with evidence. In this case, the denial is not substantiated, 
and we must find in your favor. Therefore, we decided that the Plan has to pay for the nursing care services 
provided to the enrollee on March 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient hospital services on March 04, 
2022, to March 05, 2022. 
 
You asked the Plan to waive the coinsurance for outpatient hospital services. 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 each surgical or observation room service you get at an outpatient hospital. Covered services 
include but are not limited to services in an emergency department or outpatient clinic, such as observation 
services or outpatient surgery. The provider billed in the amount of $41,056 and the allowed amount is 
$20,926.75. $20,926.75 x 20% = $4,185.35. Therefore, results in the total cost sharing amount of $4,185.25. 
 
 
 You have been asked to pay a 20% coinsurance for outpatient hospital services. This item/service falls within 
the Outpatient hospital 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 coinsurance for 
outpatient hospital services on March 04, 2022, to March 05, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy on tooth #3 (D3330), a resin-based 
composite filling on tooth #3 (D2391), and cone beam imaging (D0364) provided on January 26, 2022. 
 
You asked the Plan to pay for the dental services. You say that you received pre-approval for these services, 
but your claim was received until May. The Plan denied your request. The Plan says your annual dental 
maximum benefit has been met. The Plan also says that cone beam imaging (D0364) is not covered by your 
dental 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 this benefit includes 
coverage up to $3,500 for only the items and services listed in the covered routine dental benefits chart. The 
contract says that you are responsible for any amount above the covered benefit limit. 
 
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 is not among those 
covered under this benefit.    
 
The record shows your annual dental benefit maximum has been met. You have been asked to pay a total of 
$1,478.70 for the dental services received on January 26, 2022. These items/services fall 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 pay for endodontic therapy on tooth #3 (D3330), a 
resin-based composite filling on tooth #3 (D2391), and cone beam imaging (D0364) provided on January 26, 
2022.