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

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on August 31, 
2023. 
 
You asked the Plan to pay for a limited oral evaluation (D0140). You say that you do not understand how a 
simple limited oral examination is not covered. The Plan denied your request. The Plan says this is not a 
covered expense. 
 
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 limited 
oral evaluation (D0140) provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for footcare services provided on January 28, 2022. 
 
You asked the Plan to pay for footcare services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim was filed beyond one year of the date of service. 
This is in accordance with Medicare rules. 
 
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 footcare services was not filed until June 5, 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 footcare services provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 dental services provided on June 28, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on July 14, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you hope that the acupuncture treatments 
will provide pain relief in lieu of a more invasive procedure. The Plan denied your request. The Plan says that 
acupuncture is only covered for chronic low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you have been diagnosed with lumbago with sciatic, 
unspecified side (M54.40), and acupuncture is only covered for chronic low back pain. Therefore, we decided 
that the Plan does not have to pay for the acupuncture services provided on July 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on August 18, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image 
(D0230) provided on August 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 August 15, 2023. 
Therefore, we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic 
image (D0230) provided on August 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine foot care services provided on July 25, 2023. 
 
You asked the Plan to pay for routine foot care services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for routine foot care 
services provided on July 25, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a SPRINT peripheral nerve stimulator. 
 
You asked the Plan to pre-approve the nerve stimulator. You say that the enrollee is in severe pain and requires 
this procedure to regain the ability to do everyday activities. The Plan denied your request. The Plan says 
experimental and investigational procedures are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 nerve stimulator. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the Sprint peripheral nerve stimulator is considered experimental/investigational 
and is not medically necessary for the treatment of chronic pain. 
 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 nerve stimulator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a SPRINT peripheral nerve stimulator.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supply allowance, 
supplies and accessories provided on July 3, 2023. 
 
You asked the Plan to pay for the CGM), supply allowance, supplies and accessories. You say that you have 
submitted all relevant supporting documents to fulfill our obligations. The Plan denied your request. The Plan 
says the documentation requirements have not been met. 
 
The record does not contain a valid a description of the item(s) being delivered. Based on this information, we 
decided that Medicare rules for coverage of the CGM or receiver and supply allowance have not been met. 
Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM), supply 
allowance, supplies and accessories provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for add tooth to existing partial denture (D5650), localized 
delivery of antimicrobial agents (D4381), gingival irrigation (D4921), and drugs or medicaments dispensed in 
the office for home use (D9630) provided on June 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you want a reconsideration because periodontal 
screening was not on treatment evaluation summary, other codes were denied, and add tooth to existing partial 
denture (D5650) needs further explanation. The Plan denied your request. The Plan says your benefit for add 
tooth to existing partial denture (D5650) has already been exhausted. The Plan also says localized delivery of 
antimicrobial agents (D4381), gingival irrigation (D4921), and drugs or medicaments dispensed in the office 
for home use (D9630) 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, certain limitations apply. The record 
shows your benefit for add tooth to existing partial denture (D5650) was exhausted on date of service June 20, 
2023. The record also shows that localized delivery of antimicrobial agents (D4381), gingival irrigation 
(D4921), and drugs or medicaments dispensed in the office for home use (D9630) are not a covered benefit. 
Therefore, we decided that the Plan does not have to pay for add tooth to existing partial denture (D5650), 
localized delivery of antimicrobial agents (D4381), gingival irrigation (D4921), and drugs or medicaments 
dispensed in the office for home use (D9630) provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided on September 5, 
2023. 
 
You asked the Plan to pay for the prophylaxis. You say that the enrollee has a past history of periodontal 
treatment, manual dexterity compromised due to arthritis in her hands and fingers. You also say that three 
cleanings per year are a necessity. 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 dates of service January 5, 2023, and 
May 3, 2023. Therefore, we decided that the Plan does not have to pay for the prophylaxis - adult (D1110) 
provided on September 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for podiatry services provided on January 24, 2022. 
 
You asked the Plan to pay for podiatry services. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says the claim was filed beyond one year of the date of service. 
This is in accordance with Medicare rules. 
 
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 podiatry services was not filed until June 5, 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 podiatry services provided on January 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain or ceramic pontic (D6245) and a porcelain or 
ceramic retainer crown (D6740) provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the maximum allowed is $2,000. You also say 
the total spent this year has been $253, which is well below the $2,0000. 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 September 6, 2023. 
Therefore, we decided that the Plan does not have to pay for a porcelain or ceramic pontic (D6245) and a 
porcelain or ceramic retainer crown (D6740) provided on September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on June 5, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that that you confirmed that the acupuncture 
services were covered. The Plan denied your request. The Plan says acupuncture is only covered for chronic 
low back pain. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.   
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, your diagnosis is low back pain unspecified, and 
acupuncture is only covered for chronic low back pain. Therefore, we decided that the Plan does not have to 
pay for the acupuncture services provided on June 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for massage therapy provided on May 22, 2023. 
 
You asked the Plan to pay for massage therapy. You say that you are requesting reconsideration for the denied 
claim. The Plan denied your request. The Plan says massage is not covered or mentioned in the EOC. 
 
The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. Therefore, 
we decided that the Plan does not have to pay for massage therapy provided on May 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services provided on August 2, 2023, to September 
1, 2023. 
 
You asked the Plan to pay for physician services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says this service is denied because the provider is not 
part of the Medicare program. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for physician 
services provided on August 2, 2023, to September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for limited oral evaluation (D0140) and to 
waive the coinsurance for re-cement or re-bond crown (D2920) provided on July 27, 2023. 
 
  You asked the Plan to waive the copayment for limited oral evaluation and to waive the coinsurance for re-
cement or re-bond crown. You say that you had a crown placed in 2021 that fell off twice. You also say you do 
not feel you should be responsible for this charge since it was not your fault the original re-cement from the 
first time the crown fell off did not hold properly. 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 $15 
copayment for oral examination and cleaning. Your contract with the Plan also clearly says that you must pay 
50% coinsurance for all other covered comprehensive dental services.  
 
You have been asked to pay $7.50, which is less than the $15 copayment for limited oral evaluation. Limited 
oral evaluation falls within the oral examination and cleaning benefit category. You have also been asked to 
pay $24.44 in coinsurance, which is 50% of the allowed amount for re-cement or re-bond crown ($48.88 x 50% 
= $24.44). Re-cement or re-bond crown falls within the all other covered comprehensive 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 waive the copayment for limited oral evaluation (D0140) and to waive 
the coinsurance for re-cement or re-bond crown (D2920) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement implant body (D6010), prefabricated 
abutment (D6056) and abutment supported porcelain to metal crown (D6060) provided on November 28, 2022, 
to March 31, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered services. 
 
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 surgical 
placement implant body (D6010), prefabricated abutment (D6056) and abutment supported porcelain to metal crown (D6060) provided on November 28, 2022, to March 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 70100, 70360, 72040, 74230, 74240, and 
99203 provided on August 8, 2023.  
You asked the Plan to pay for procedure codes 70100, 70360, 72040, 74230, 74240, and 99203. You say that 
you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for mobile units serving an entity with its own POS 
code, the entity's POS code should be reported. Medicare rules also say that the technical component of a 
portable x-ray service during the course of a Medicare-covered stay in a skilled nursing facility (SNF), 
representing the procedure itself, including any associated transportation and setup costs, would be subject to 
consolidated billing (the SNF bundling requirement for services furnished to the SNFs Part A residents), and 
must be included on the SNFs Part A bill for the residents covered stay rather than being billed separately 
under Part B. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the billed services (70100, 70360, 72040, 74230, 74240, and 99203) have not been met. The 
documentation supports that the enrollee was at a skilled nursing facility setting on the date of service. As such, 
the use of the office POS code is not appropriate. Therefore, we decided that the Plan does not have to pay for 
procedure codes 70100, 70360, 72040, 74230, 74240, and 99203 provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible amounts for the medical examination and 
evaluation (92014), eye refraction (92015), and eye exam with photos (92250) provided on July 24, 2023. 
 
You asked the Plan to waive the deductible amounts for the medical examination and evaluation, eye 
refraction, and eye exam with photos. You say that eye exams are covered in full once per year from an in-
network provider, and a $65 copay is applied when the exam is from an out-of-network provider. You also say 
that other than the copay, this claim should have been paid in full. 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 $1,000 deductible which applies to vision services.  
 
 
 
 
 The services you asked the Plan to waive the deductible amounts for fall within the vision services benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 
deductible which applies to vision services. This cost sharing is a contractual obligation that had not been met 
at the time the medical examination and evaluation, eye refraction, and eye exam with photos was received on 
July 24, 2023. Therefore, we decided that the Plan does not have to waive the deductible amounts for the 
medical examination and evaluation (92014), eye refraction (92015), and eye exam with photos (92250) 
provided on July 24, 2023.