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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
May 26, 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 March 30, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on May 26, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services after August 16, 2023. 
 
You asked the Plan to pre-approve SNF services after August 16, 2023. You say that you have not regained the 
strength need to return home. You also say you need this therapy and equipment to assist you with walking. 
The Plan denied your request. The Plan says you will have used your 100 days by August 16, 2023. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from February 17, 2023, to 
August 16, 2023. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pre-approve  SNF services after August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing service (V5299), sales tax 
(S9999), hearing aid or assisted listening device (V5267), and the hearing aids (V5298) purchased on April 18, 
2023. 
 
You asked the Plan to issue reimbursement for the items/services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing 
aids/services are not payable as they were rendered by 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 from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from 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 service (V5299), 
sales tax (S9999), hearing aid or assisted listening device (V5267), and the hearing aids (V5298) purchased on 
April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 13, 
2022. 
 
You asked the Plan to pay for the prophylaxis - adult. You say that there should not be a charge for 2 cleanings 
per year. You also say that if the Plan was not going to pay you would have cancelled your appointment and 
rescheduled in the first part of 2023. The Plan denied your request. The Plan says your benefit for the requested 
service $1,000 dollar limit was met. 
 
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 prophylaxis - adult has been exhausted. The Plan has provided evidence of having 
made payments totaling $1,000 towards the cost of dental services provided in 2022. Therefore, we decided 
that the Plan does not have to pay for a prophylaxis - adult (D1110) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for application of caries arresting medicament  per tooth 
(D1354) provided on February 7, 2023. 
 
You asked the Plan to pay for the application of caries arresting medicament  per tooth. The Plan denied your 
request. The Plan says your plan does not cover this procedure. 
 
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 
application of caries arresting medicament  per tooth (D1354) provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation (D9310) provided on May 11, 2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan sent you a list of contracting dentists 
and the service should be covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the consultation 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
consultation (D9310) provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) and the palliative 
treatment of dental pain (D9110) provided on April 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are dissatisfied with the denial letter. The 
Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
intraoral radiographic image and the palliative treatment of dental pain 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 the 
intraoral radiographic image (D0220) and the palliative treatment of dental pain (D9110) provided on April 6, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit (D9431), an 2D oral imaging (D0350), 
provided on February 22, 2023. 
 
You asked the Plan to pay for D9431 and D0350. You say that you were never told that these services were not 
covered. The Plan denied your request. The Plan says the rendered dental services are not covered benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an office 
visit (D9431), an 2D oral imaging (D0350), provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an unspecified periodontal procedure (D4999), oral 
hygiene instructions (D1330), intraoral imaging (D0210), panoramic images (D0330), and 2D oral images 
(D0350), provided on January 3, 2023. 
 
You asked the Plan to pre-approve the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says this dental work has been 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, certain limitations apply. The record 
shows your benefit for D0210, D0330, and D0350 was exhausted on date of service January 3, 2023. D4999 
and D1330 are not covered benefits. Therefore, we decided that the Plan does not have to pre-approve an 
unspecified periodontal procedure (D4999), oral hygiene instructions (D1330), intraoral imaging (D0210), 
panoramic images (D0330), and 2D oral images (D0350), provided on January 3, 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 April 5, 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 April 5, 2023. Therefore, 
we decided that the Plan does not have to pay for intraoral - periapical each additional radiographic image (D0230) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 12, 
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 December 21, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would have had to wait two months to see 
an in-network provider. 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 surgical extraction (D7210) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the sales tax (S9999) and the hearing aids 
(V5298) purchased on March 9, 2023. 
 
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 from the Plans select hearing aid provider.  
 
We looked at this 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 Plans contract states that hearing aids are covered 
only when purchased from 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 sales tax (S9999) and the hearing aids (V5298) purchased on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. 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 May 26, 2022, and 
September 1, 2022. Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided 
on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the comprehensive series 
of radiographic images (D0210), and a cleaning (D1110) provided by an out-of-network provider on March 21, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you called the Plan and were told that the dental 
cleaning would 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. Also, it was verified that you 
were given the proper benefits and provider eligibility prior to the date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the comprehensive series of radiographic images (D0210), and a 
cleaning (D1110) provided by an out-of-network provider on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740) provided on November 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services should be covered. The Plan 
denied your request. The Plan says the enrollee's dental annual maximum allowance amount was 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 annual dental allowance amount was exhausted on date of service November 19, 2022. Therefore, we 
decided that the Plan does not have to pay for the remaining charges for crowns (D2740) provided on 
November 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a limited oral evaluation - problem 
focused (D0140) provided on May 16, 2023. We also decided that the Plan does not have to pay for the cone 
beam CT image capture with limited field of view  less than one whole jaw (D0380) provided on May 16, 
2023. 
 
You asked the Plan to waive the coinsurance for the limited oral evaluation and pay for the cone beam CT 
image capture. You say that you do not feel you are liable for the services rendered. The Plan denied your 
request. The Plan says this cost sharing was charged 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 cone beam CT image capture is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT image capture with limited field of view  less than one whole jaw (D0380) provided on May 16, 
2023. 
 
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 enrollees must pay a 
50% coinsurance for preventive and comprehensive dental services of the billed charges up to the $4,000 
allowance for all out-of-network covered dental services. 
 
You have been asked to pay a 50% coinsurance for the limited oral evaluation. This service falls within the 
preventive and comprehensive dental out-of-network benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
coinsurance for a limited oral evaluation - problem focused (D0140) provided on May 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 17, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you require this type of dental cleaning, and it is 
no different than a regular cleaning other than checking for bone loss. The Plan denied your request. The Plan 
says this service is not a covered benefit under your dental 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 the 
periodontal maintenance (D4910) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2D oral/facial photographic image obtained intra-orally or 
extra-orally (D0350) provided on March 24, 2023. 
 
You asked the Plan to pay for the dental service. You say that the services should be covered. 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. The 2D oral/facial 
photographic image obtained intra-orally or extra-orally (D0350) is not covered under the Plans dental 
benefits 
 
  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 2D 
oral/facial photographic image obtained intra-orally or extra-orally (D0350) provided on March 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns (D2750 x 2) provided on March 20, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your provider led you to believe these 
procedures would be covered by your insurance. 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 March 20, 2023. 
Therefore, we decided that the Plan does not have to pay more for the crowns (D2750 x 2) provided on March 
20, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on April 5, 2022, to April 26, 
2022. 
 
You asked the Plan to pay for home health services. You say that you do not agree with the denial of payment 
for home health services. The Plan denied your request. The Plan says the NOA was not received timely. As 
such, this final claim was correctly denied.  
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is April 5, 2022. The NOA was not received by the Plan until May 9, 2022. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for home health services provided on April 
5, 2022, to April 26, 2022.