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

 
We decided that the Plan does not have to pay for dental services provided by an oral surgeon on September 
10, 2021. 
 
You asked the Plan to pay for dental services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says this claim has been correctly denied. 
 
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 dental 
services when the services are provided by a general dentist.  
 
We looked at the file and Medicare rules. The rendering provided is an oral surgeon. Based on this information, 
we decided that the Plan's rules for coverage of dental services have not been met. Therefore, we decided that 
the Plan does not have to pay for dental services provided by an oral surgeon on September 10, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal scaling and root planing and 
porcelain/ceramic crown rendered on February 14, 2022. 
 
You asked the Plan to pay for these services. You say that you were told by the provider the services would be 
covered. The Plan denied your request. The Plan says the services are not covered. 
 
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 
periodontal scaling and root planing and porcelain/ceramic crown rendered on February 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance service you received on 
November 3, 2021. 
 
You asked the Plan to pay for the periodontal maintenance service. You say that you do not have record of 
receiving a covered periodontal maintenance service in 2021. The Plan denied your request. The Plan says you 
had already exhausted your benefit for this service for the year. 
 
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's contract says that 
periodontal maintenance is only covered once per 12 months.  Records show that you already received a 
covered periodontal maintenance service on August 2, 2021, so you were not eligible for another one on the 
date of service in question. 
 
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 
periodontal maintenance service you received on November 3, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the biopsy services provided on February 19, 2022. 
 
You asked the Plan to pay for the biopsy services. You say that this service should be paid under your medical 
benefit. The Plan denied your request. The Plan says that the services are not covered. 
 
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. We received additional information from the enrollee that requests dental code 
D7286 be paid under the enrollee's medical benefit and not under the dental benefit. The enrollee received this 
biopsy for the possibility of cancer on the upper hard palate, which is part of the facial skeleton. The Plan 
provided no medical records in order to determine if the services were medical in nature. We find that the Plan 
has not provided sufficient evidence to show that their denial of payment is based on Medicare criteria. 
Therefore, we decided that the Plan has to pay for the biopsy services provided on February 19, 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation (D7953) 
for tooth #30. 
 
You asked the Plan to pre-approve a bone replacement graft. You say that the requested procedure is medically 
necessary. The Plan denied your request. The Plan says the procedure code is not listed and therefore 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 pre-approve a 
bone replacement graft for ridge preservation (D7953) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the upper partial (code D5211), dental extractions (code 
D7210 and code D7140), and other prosthodontic (code D6999) you received from October 25, 2021, to 
November 9, 2021. 
 
You asked the Plan to pay for the upper partial, dental extractions , and other prosthodontic. You say that when 
you went to see your dentist for a routine cleaning, it was discovered that the two teeth of your bridge were 
decayed under the crowns. You were experiencing drainage and pain that required removal of the affected 
teeth.  It was also necessary to cut the small portion of the bridge to save the one remaining tooth. The Plan 
denied your request. The Plan says these services are not covered. 
 
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.  Your dental plan only covers the following dental services, regardless of the necessity of the service: oral exams, cleanings, fluoride 
treatments, and x-rays. 
 
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 upper 
partial (code D5211), dental extractions (code D7210 and code D7140), and other prosthodontic (code D6999) 
you received from October 25, 2021, to November 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series dental x-rays you received on February 3, 
2022. 
 
You asked the Plan to pay for the complete series dental x-rays. You say that this office is listed on the Plan's 
list of dentists.  You also said that the dentist accepted your insurance card.  As a new patient, the dentist 
wanted to take new x-rays. The Plan denied your request. The Plan says you had already exhausted your 
complete series dental x-ray benefit for 2022. 
 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. Your Plan contract says that 
you are covered for one complete series dental x-ray once every 5 years.  Records show that you already 
received a covered complete series dental x-ray on July 19, 2017.  You are not eligible for coverage of this 
service again until after July 19, 2022. 
 
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 
complete series dental x-rays you received on February 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D9910, D4921) provided to you on 
January 24, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says these services 
are not covered. 
 
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 services are not among 
those covered under this benefit. The Plan only covers those dental services for which the codes are listed in 
the Evidence of Coverage. Dental codes D9910 and D4921 are not listed, and therefore are not covered. 
Therefore, we decided that the Plan does not have to pay for the dental services (D9910, D4921) provided to 
you on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental surgical extraction (code D7210) you had on 
February 9, 2022. 
 
You asked the Plan to pay for the dental surgical extraction. You say that the dentist just numbed your mouth 
and pulled the tooth so that it was outside of the bone. The Plan denied your request. The Plan says dental 
surgical extractions are not covered under your dental 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. Your dental benefit explicitly 
excludes coverage for surgical extractions.  Your dentist billed for a surgical extraction. 
 
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 
surgical extraction (code D7210) you had on February 9, 2022.  
 Your complaint about how the dentist categorized your extraction is not a valid appeal for medical coverage. 
This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to 
make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the panoramic dental x-ray (code D0330) and the comprehensive oral exam (code D0150) you had on February 9, 2022.
You asked the Plan to pay for the panoramic dental x-ray and the comprehensive oral exam. You say that you believe the dentist should have verified your benefits before performing these services. You said that you cannot afford this bill. The Plan denied your request. The Plan says you were not eligible for these services on the date of service in question.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit includes coverage of panoramic dental x-rays once every 5 years and comprehensive oral exams once every 3 years. Records show that you already received covered panoramic dental x-rays on August 8, 2019, and you already received a covered comprehensive dental exam on September 15, 2020. Because of this, you were not eligible for these services again on February 9, 2022. 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 panoramic dental x-ray (code D0330) and the comprehensive oral exam (code D0150) you had on February 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that none of the physical therapists in your city 
take accept this Plan, and the one that does take it is 27 miles away from your home. You also say that your 
vehicle gets eighteen miles per gallon, and that round trip will cost you about $15 with gas prices of $5 per 
gallon. You also say that if you can go to a physical therapist in your town, you can walk to it. The Plan denied 
your request. The Plan says your health records must show that you have been seen by a contracted physical 
therapy facility before an out-of-plan facility visit will be approved. Based on the Plan's policy for out-of-
network requests, the service must be emergent or not available within the Plan network in order to use a non-
contracted provider. The Plan also says that the services you need are available from a contracted physical 
therapy facility that is a part of your health plan network. 
 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 
physical therapy to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a chest x-ray provided on January 27, 
2022, and a stress test provided on February 9, 2022. 
 
You asked the Plan to reduce the copayment for an x-ray and stress test. You say that you were expecting a $35 
copayment for each test. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $35 
copayment for basic imaging service, including x-rays. The contract also says that enrollees must pay a $200 copayment for advanced imaging services, including stress tests. 
 
You have been asked to pay a $35 copayment for an x-ray on January 27, 2021. You have also been asked to 
pay a $200 copayment for a stress test on February 9, 2022. An x-ray and stress test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies 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 reduce the 
copayment for a chest x-ray provided on January 27, 2022, and a stress test provided on February 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental extractions you had on December 21, 2021. 
 
You asked the Plan to pay for the dental extractions. You say that you believe you are covered for unlimited 
dental extractions. The Plan denied your request. The Plan says you have exhausted your dental extraction 
benefit for 2021. 
 
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.  It appears that you quoted 
Dental Plan 376 in your appeal request.  Under Dental Plan 376, there is unlimited coverage for dental 
extractions.  However, you are not enrolled in Dental Plan 376.  Rather, the Plan has provided evidence that 
you are enrolled in Dental Plan 127.  Under Dental Plan 127, you are covered for two dental extractions per 
calendar year.  You had already received two covered dental extractions for 2021 prior to December 21, 2021. 
 
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 
extractions you had on December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Partially Favorable

 
We decided that the Plan has to pay $1000 towards the crown you received on September 7, 2021. We decided 
that the Plan does not have to pay anything beyond $1000 towards the crown you received on September 7, 
2021.  
 
You asked the Plan to pay for the crown you received on September 7, 2021. You say that you cannot afford 
this crown. The Plan says that you have exhausted your dental benefit for 2021. 
 
We decided that the Plan has to pay $1000 towards the crown you received on September 7, 2021.  
Medicare rules state that it is the Plans obligation to justify its denial of payment and to provide sufficient 
documentation supporting its denial to us.  In this case, the Plans sole denial rationale for payment for this 
crown is that you had exhausted your dental benefit for 2021.  However, the Plan has failed to provide any 
documentation proving how you exhausted this benefit.  They have provided no breakdown of paid services, no 
copies of paid claims, etc. that would have supported their denial rationale.  This is all information and 
documentation that is within the Plans control.  The Plans failure to supply this required information when 
they submitted their case file to us means that they have not supported their denial.   
 
With that said, your dental benefit is limited to $1000 per year, so the Plan cannot be obligated to pay more 
than that towards this crown.  Therefore, we decided that the Plan has to pay $1000 towards the crown you 
received on September 7, 2021.  
 
We also decided that the Plan does not have to pay $1000 towards the crown you received on September 
7, 2021. Medicare generally does not cover dental services, so the Plans contract document controls coverage 
of your dental benefits.  Your dental benefits state that you are covered up to $1000 for dental services per 
calendar year.  Because the crown you received cost more than $1000, the Plan cannot be obligated to pay 
more than $1000 towards this crown.  Therefore, we decided that the Plan does not have to pay more than 
$1000 towards the crown you received on September 7, 2021. 
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from May 21, 2022, forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from May 21, 2022, forward. You say that the 
requested services are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of inpatient psychiatric care from May 
21, 2022, forward. have been met. There are no medical records within the casefile. Without the requested 
clinical information, we are unable to determine if the requested services are medically necessary. Therefore, 
we decided that the Plan does not have to pre-approve inpatient psychiatric care from May 21, 2022, forward.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
intraoral, complete series of radiographic images (D0210). 
 
You asked the Plan to pre-approve a comprehensive oral evaluation and an intraoral, complete series of 
radiographic images. You say that you are in a lot of pain and were denied x-rays and an oral exam. You are 
requesting reconsideration of the denied procedures. The Plan denied your request. The Plan says your benefit 
for the requested procedures have been exhausted for the 2022 plan year. 
 
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 a 
comprehensive oral evaluation and an intraoral, complete series of radiographic images once every 3 calendar 
years.  
 We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation 
and a complete series of radiographic images on April 19, 2022, therefore, you have exhausted your maximum 
benefit for these services. Based on this information, we decided that the Plan's rules for coverage of a 
comprehensive oral evaluation and an intraoral, complete series of radiographic images have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and 
an intraoral, complete series of radiographic images (D0210).