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

 
We decided that the Plan does not have to pay for the dental services on July 21, 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 July 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that your current dentures do not fit anymore, 
and you cannot eat properly with them. 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 September 22, 
2021. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture (D5213) and a 
partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 7, 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 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 dental services on July 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an upper partial denture (D5213). 
 
You asked the Plan to pay for the dental services. You say that the enrollee lost the upper partial denture 
provided in April. You say the enrollees overall health and oral health benefited greatly from the partial 
denture and would like for code D5213 to be approved. The Plan denied your request. The Plan says the benefit 
for the requested item 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 that the benefit for the requested item was exhausted on date of service April 21, 2022. Therefore, we 
decided that the Plan does not have to pay for an upper partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on January 6, 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 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 dental services on January 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for guided tissue regeneration and a bone replacement graft 
(D7953, D4267) provided on July 21, 2022 
 
You asked the Plan to pay for the guided tissue regeneration and a bone replacement graft. 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 guided 
tissue regeneration and a bone replacement graft (D7953, D4267) provided on July 21, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation services (D4921) 
 
You asked the Plan to pre-approve the gingival irrigation 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 pre-approve 
gingival irrigation services (D4921)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the placement of an intra-socket biological dressing 
(D7922). 
 
You asked the Plan to pre-approve a biological dressing. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says the placement of an intra-socket biological dressing 
(D7922) is 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 pre-approve the 
placement of an intra-socket biological dressing (D7922).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) for tooth #6 provided on 
June 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist said it was medically necessary to 
get a bone graft done. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because bone replacement grafts are 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 a bone 
replacement graft (D7953) for tooth #6 provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain/ceramic 
(D2740) provided on December 15, 2021. 
 
You asked the Plan to provide additional payment for the crown. You say that you expect the Plan to provide 
coverage for necessary services. The Plan denied your request. The Plan says you have exhausted your dental 
allowance. 
 
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 crown up 
to your $1,000 dental maximum.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that at the time your 
claim was processed you had $815 remaining in your dental allowance. The Plan has reprocessed your claim 
and applied the $815 to this service. You are responsible for any remaining amount above your dental 
maximum. Therefore, we decided that the Plan does not have to provide additional payment for the crown - 
porcelain/ceramic (D2740) provided on December 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based filling (D2331) for tooth #25 provided on June 
10, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not know you had this procedure done 
already this year. 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 April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for a resin-based filling (D2331) for tooth #25 
provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral periapical x-ray of tooth #10 (D0220) provided 
on August 29, 2022. 
 
You asked the Plan to pay for the dental imaging. You say that previous x-ray services were covered. The Plan 
denied your request. The Plan says the x-ray at issue is not a covered benefit. The claim was processed 
correctly. 
 
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 
intraoral periapical x-ray of tooth #10 (D0220) provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an x-ray (D0270) provided on June 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that your dentist said you needed the x-ray because 
you were in 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 the date of service of June 23, 2022, the 
Plan paid for 1 x-ray on the same date. Therefore, we decided that the Plan does not have to pay for an x-ray 
(D0270) provided on June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive evaluation (D0150) provided on June 23, 
2022. 
 
You asked the Plan to pay for the dental services. You say that you only went in for a cleaning and the provider 
never asked you to do an evaluation. 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 June 14, 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive evaluation (D0150) provided on 
June 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on July 15, 2022 
 
You asked the Plan to pay for the core buildup 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 core 
buildup services (D2950) provided on July 15, 2022
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image, intraoral - 
periapical each additional radiographic image, topical application of fluoride varnish, and periodontal scaling 
and root planing - one to three teeth per quadrant x2 provided on June 22, 2022. 
  You asked the Plan to pay for dental services. You say that you do not feel you should be paying for the 
services you received. The Plan denied your request. The Plan says intraoral - periapical first radiographic 
image, intraoral - periapical each additional radiographic image and topical application of fluoride varnish are 
not covered under the Plan. The periodontal scaling and root planing - one to three teeth per quadrant is 
covered with limitations. 
 
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. Intraoral - periapical first 
radiographic image, intraoral - periapical each additional radiographic image, topical application of fluoride 
varnish are not covered under the Plans dental benefits.  Periodontal scaling and root planing - one to three 
teeth per quadrant  one every three calendar years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested intraoral - periapical first 
radiographic image, intraoral - periapical each additional radiographic image and topical application of fluoride 
varnish are not among those covered under this benefit. You previously received periodontal scaling and root 
planing  four or more teeth per quadrant on March 9, 2020. Therefore, this benefit has been exhausted as of 
March 9, 2020. Therefore, we decided that the Plan does not have to pay for intraoral - periapical first 
radiographic image, intraoral - periapical each additional radiographic image, topical application of fluoride 
varnish, and periodontal scaling and root planing - one to three teeth per quadrant x2 provided on June 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete upper dentures (D5110) provided on July 12, 2022. 
 
You asked the Plan to pay for dental services. You say that you have been missing the tooth since 1984 and has 
had multiple plates. The Plan denied your request. The Plan says the service is covered but limitations apply. 
 
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. This benefit includes complete 
upper dentures (D5110) but the following services, supplies or charges are excluded if the issue started prior to 
the individuals effective date or after the termination date of coverage under this contract (for example but not 
limited to, multi-visit procedures such as endodontics, crown, bridges, inlays, onlays, and dentures). 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete upper dentures 
(D5110) are not among those covered under this benefit if the issue started prior to the individuals effective 
date or after the termination date of coverage under this contract. You stated that you have had an issue since 
1984, which is prior to your effective date for this coverage. Therefore, we decided that the Plan does not have 
to pay for complete upper dentures (D5110) provided on July 12, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cancer panel testing provided on June 14, 2022. 
 
You asked the Plan to pay for the panel testing. You say that the testing clarifies disease risk. The Plan denied 
your request. The Plan says the testing is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. The records show that the testing at issue is not FDA approved. 
There are no medical records from the treating physician to show a clinical indication for the testing. Based on 
this information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided 
that the Plan does not have to pay for the cancer panel testing provided on June 14, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on January 22, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the transport took place before the enrollee 
was enrolled in hospice. The Plan denied your request. The Plan says the enrollees claim would be covered 
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until 
the last day of the month in which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services and to know proper billing procedures for a Medicare 
Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport (A0428), and ground mileage (A0425) provided on January 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for telehealth specialist visit provided on 
March 17, 2022. 
 
You asked the Plan to waive the copayment for telehealth specialist visit. You say that you are disputing the 
share cost. 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 $30 
copayment for physician/practitioner services, including doctor's office visits.  
 
You have been asked to pay $30 copayment for telehealth specialist visit. This item/service falls within the 
physician/practitioner services, including doctor's office visits 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 telehealth specialist visit provided on March 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 2, 2022, to July 26, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on May 2, 2022, to July 
26, 2022, by an out-of-network (OON) provider.