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

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220 and D0230) 
provided on December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that you feel the x-rays were not needed and if there 
was a charge with a free cleaning you should have been informed. The Plan denied your request. The Plan says 
your benefit for the requested items or services 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 items or services was exhausted on the date of service of November 3, 
2022. Therefore, we decided that the Plan does not have to pay for the intraoral radiographic images (D0220 
and D0230) provided on December 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve tracheostomy shower protectors (A7523). 
 
You asked the Plan to pre-approve tracheostomy shower protectors. You say that these items are necessary. 
The Plan denied your request. The Plan says the requested items are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that tracheostomy shower protectors (A7523) are a 
convenience item and therefore not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of tracheostomy shower protectors have not been met. Therefore, we decided that the Plan does not 
have to pre-approve tracheostomy shower protectors (A7523).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on 
September 8, 2021. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the service is not payable as the claim was 
submitted untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for this service was not filed until January 4, 2023. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the chiropractic manipulative treatment (98941) provided on September 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298 x 2) and the sales 
tax (S9999) purchased on May 26, 2022. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased through the Plans select hearing aid provider.   
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plan contract states that coverage is provided for 
hearing aids only when purchased through the Plans select hearing aid provider. However, the hearing aids in 
this case were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids (V5298 x 2) and the sales tax (S9999) purchased on May 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the primary care office visit and x-ray 
provided from November 9, 2022, to November 17, 2022. 
 You asked the Plan to waive the copayment for the office visit and x-ray. You say that this was an annual 
wellness visit and a follow-up to a previous procedure. 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 
copayment for each in-network primary care provider office visit. Your contract with the Plan also clearly says 
that you must pay a $20 copayment for each in-network x-ray provided by a specialist.   
 
You have been asked to pay a $10 copayment for the office visit. This item/service falls within the 
physician/practitioner services benefit category. You have also been asked to pay a $20 copayment for the x-
ray. This item/service falls within the outpatient diagnostic tests and therapeutic services benefit category. You 
have been asked to pay a total of $30 ($10 copayment + $20 copayment = $30). 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 primary care office visit and x-ray provided from November 9, 2022, to 
November 17, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the lumbar injections provided on 
November 28, 2022, to January 6, 2023. 
 
You asked the Plan to reduce the copayments for the lumbar injections. You say that you did not expect such a 
large 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 $300 
copayment for each in-network Medicare-covered outpatient surgery or procedure provided at an outpatient 
hospital facility.  
 
You have been asked to pay a $300 copayment for each lumbar injection. You have been asked to pay a total of 
$600 ($300 copayment x 2 injections = $600). These items/services fall within the outpatient surgery, including 
services provided at hospital outpatient facilities 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 reduce the 
copayments for the lumbar injections provided on November 28, 2022, to January 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve special supplemental benefits for the chronically ill 
(SSBCI). 
 
You asked the Plan to pre-approve SSBCI benefits. The Plan denied your request. The Plan says the criteria for 
eligibility have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that, to qualify for SSBCI, an enrollee must have a 
documented chronic condition that is life threatening or significantly limits the health or function of the 
enrollee, has a high risk of hospitalization or adverse health outcomes, and requires intensive care coordination.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SSBCI benefits have not been met. Specifically, we have confirmed that the enrollee does not have 
an eligible condition that meets all the required criteria. Therefore, we decided that the Plan does not have to 
pre-approve special supplemental benefits for the chronically ill (SSBCI).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0367) 
provided on October 7, 2022. 
 
You asked the Plan to pay for the CT scan. 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 Plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a cone beam computed 
tomography (CT) scan (D0367) provided on October 7, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayments for the wound debridement and compression 
bandage application services provided from November 3, 2022, to November 30, 2022. 
 
You asked the Plan to reduce the copayments for the wound care services. You say that each visit should only 
have a $25 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 $25 
copayment for each specialist service. Your contract with the Plan also clearly says that you must pay a $175 
copayment for each surgical service provided at an outpatient hospital. You have been asked to pay a $25 copayment for each wound debridement service. These items/services fall 
within the physician/practitioner services benefit category. According to Medicare the compression bandage 
application (code 29581) is considered a surgical service. You have been asked to pay a $175 copayment for 
each compression bandage application service. These items/services fall within the outpatient 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 reduce the copayments for the wound debridement and compression 
bandage application services provided from November 3, 2022, to November 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and panoramic 
radiographic image (D0330) provided on December 6, 2022. 
 
We decided that the Plan does not have to pay for intravenous moderate (conscious) sedation/analgesia - each 
subsequent 15-minute increment (D9243), intravenous moderate (conscious) sedation/analgesia - first 15-
minutes (D9239) provided on December 6, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you would like the services paid for, the 
only provider that was available at the time was a non-participating provider. The Plan denied your request. 
The Plan says you are responsible for any charged amount above the Plans cost-sharing amount when your 
services are received from an out-of-network provider. 
 
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 contract also says that 
enrollees may be billed by the out-of-network provider for any charged amount greater than the payment made 
by the Plan. This benefit includes only those items and services specifically listed in your Plan contract. 
Intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243) and 
intravenous moderate (conscious) sedation/analgesia - first 15-minutes (D9239) are not covered under the 
Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D9243 and D9239 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
intravenous moderate (conscious) sedation/analgesia - each subsequent 15-minute increment (D9243), 
intravenous moderate (conscious) sedation/analgesia - first 15-minutes (D9239) provided on December 6, 
2022. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. 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 more for extraction, erupted tooth requiring removal 
of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) and 
panoramic Radiographic Image (D0330) provided on December 6, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically 
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to only require short-term additional acute care services that can 
safely be administered at the current facility until more appropriate for a lower level of care. The enrollee does 
not require services at the LTACH that are not already available at the current facility.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated stainless steel crown-permanent tooth 
(D2931) provided on December 7, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item 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, this item is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pay for the prefabricated stainless steel 
crown-permanent tooth (D2931) provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified removable prosthodontic procedure, by report 
(D5899) x2 provided on October 31, 2022. 
 
You asked the Plan to pay for dental services. You say that you say that dentures are supposed to be a covered 
benefit. You do not understand why you are receiving a bill stating your dentures were not paid for. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Unspecified removable 
prosthodontic procedure, by report (D5899) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5899 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for unspecified 
removable prosthodontic procedure, by report (D5899) x2 provided on October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation, bitewing x-rays, and a 
cleaning (D0274, D1110, D0120) provided on December 20, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
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 the difference between the out-of-network providers charges and the Plans 
payment. 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 more for a periodic oral evaluation, bitewing x-rays, 
and a cleaning (D0274, D1110, D0120) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140) and the 
intraoral-periapical first radiographic image (D0220) provided on December 19, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit under 
your supplemental dental policy. 
 
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 services provided are not among 
those covered under this benefit.  Therefore, we decided that the Plan does not have to pay for the limited oral evaluation-problem focused 
(D0140) and the intraoral-periapical first radiographic image (D0220) provided on December 19, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the hip x-ray provided on September 27, 
2022. 
 
You asked the Plan to waive the deductible for the hip x-ray. You say that you want to make sure these charges 
were processed correctly. 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. Your 
contract with the Plan says that there is a $395 deductible which applies to x-rays. Your contract with the Plan 
also clearly says that you must pay a $45 copayment after meeting the deductible for each x-ray. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $395 deductible which applies to x-rays. This cost sharing is a contractual obligation that had not been met at the time the hip x-ray was received on September 27, 2022. Therefore, we decided that the 
Plan does not have to waive the deductible for the hip x-ray provided on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140), and 
extraction, erupted tooth or exposed root provided on November 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency abscess and claim should 
not be denied. 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 limited oral evaluation - problem focused 
(D0140), and extraction, erupted tooth or exposed root provided on November 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the ferric carboxymaltose injection and drug 
administration provided on August 24, 2022. 
 
You asked the Plan to waive the cost share for the injection and drug administration. You say that you do not 
know why this is not covered, and you cannot afford to pay this regularly. 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 20% 
coinsurance for in-network Medicare Part B drugs. Your contract with the Plan also clearly says that you must 
pay a $250 copayment for in-network surgical or other services provided at an outpatient hospital.  
 
You have been asked to pay $166.20, which is 20% coinsurance of the allowed amount for the injection ($831 
allowed amount x 20% coinsurance = $166.20). This item/service falls within the Medicare Part B drugs 
benefit category.  
 
You have also been asked to pay $194.50, which is less than the standard $250 copayment for the drug 
administration. This item/service falls within the outpatient surgery benefit category. You have been asked to 
pay a total of $360.70 ($166.20 coinsurance + $194.50 copayment = $360.70). 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 cost share for the ferric carboxymaltose injection and drug administration provided on August 24, 
2022.