Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 29, 2023, by an OON 
provider.  
 
You asked the Plan to pay for an office visit. You say that you are requesting reconsideration of the denied 
claim. The Plan denied your request. The Plan says the service was not authorized. 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 Plan contract says the enrollees POS benefit only applies to 
covered routine dental services. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for an office visit provided on June 29, 2023, by an 
OON provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure (64628, 64629). 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the requested services are a medical 
necessity for the enrollee. 
 The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
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 an Intracept procedure. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there is no magnetic resonance imaging (MRI) scan showing only modic changes 
without facet degenerative joint disorder (DJD) or stenosis. The cause of the enrollee's pain is not clear. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure (64628, 64629).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consultation (D9310). 
 
You asked the Plan to pre-approve the dental service. You say that you need the dental service approved 
because you need a procedure to have a broken tooth fixed. The Plan denied your request. The Plan says the 
denial of authorization 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 pre-approve a 
consultation (D9310).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns (D2740), resin-based composites (D2392) and a core 
build-up (D2950) provided on April 26, 2023, to June 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that if you knew you only had a $2,000 balance you 
would have rescheduled the dental procedures. The Plan denied your request. The Plan says these services have 
been processed and denied properly. 
 
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 annual dental allowance amount was exhausted on date of service April 26, 2023. D2950 is not a covered dental benefit. Therefore, we decided that the Plan does not have to pay for crowns (D2740), resin-
based composites (D2392) and a core build-up (D2950) provided on April 26, 2023, to June 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a periodic oral evaluation (D0120), the 
intraoral radiographic images (D0220 and D0230), the bitewings (D0274), and a cleaning (D1110) provided by 
an out-of-network provider on June 26, 2023. 
 You asked the Plan to waive the coinsurance for the dental services. You say that you were never informed of 
the changes with your dental plan, and you want to stay with your provider. 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 50% 
coinsurance for the total allowed amount for all routine (preventive and comprehensive) dental services when 
you receive the services from an out-of-network provider. The total allowed amount for the dental services was 
$345 and the coinsurance was $172.50 ($345 allowed x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance for the dental services. This item/service falls within the 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 coinsurance for a periodic oral evaluation 
(D0120), the intraoral radiographic images (D0220 and D0230), the bitewings (D0274), and a cleaning 
(D1110) provided by an out-of-network provider on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for teledentistry asynchronous (D9996) provided on March 28, 
2023. 
 
You asked the Plan to pay for D9996. You say that this should be covered 100%. The Plan denied your request. 
The Plan says the rendered dental service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
teledentistry asynchronous (D9996) provided on March 28, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network eye procedure provided on 
June 5, 2023. 
 
You asked the Plan to waive the deductible for an in-network eye procedure. You say that you had already met 
the $1000 deductible at the time of this procedure. You should only owe the $250 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. Your 
contract with the Plan says that there is a $1000 deductible and a $250 copayment which applies to outpatient 
surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers.  
 
You have been asked to pay a $1250 cost for this procedure ($1000 deductible + $250 copayment = $1250). 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient surgery, including 
services provided at hospital outpatient facilities and ambulatory surgical centers benefit category.  The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1000 deductible and 
a $250 copayment which applies to outpatient surgery, including services provided at hospital outpatient 
facilities and ambulatory surgical centers. This cost sharing is a contractual obligation that had not been met at 
the time an in-network eye procedure was received on June 5, 2023. Therefore, we decided that the Plan does 
not have to waive the deductible for an in-network eye procedure provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for adding a tooth to an existing partial denture 
(D5650 x2) provided on May 16, 2023. 
 
You asked the Plan to waive the copayment for the dental services. You say that the services should be covered 
as you disagree with the denial. The Plan denied your request. The Plan says the cost-sharing applied correctly 
based on the services provided. 
 
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 a $146 copayment for partial denture additions. This item/service falls within the 
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 adding a tooth to an 
existing partial denture (D5650 x2) provided on May 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on June 22, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that the enrollee did not go out-of-network. The Plan 
denied your request. The Plan says enrollees must receive their care from a network provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
items/services at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the lab services provided on June 22, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided on June 
30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 20, 2021. 
Therefore, we decided that the Plan does not have to pay for panoramic radiographic images (D0330) provided 
on June 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic images (D0330), and a 2D 
cephalometric radiographic image (D0340) provided on January 11, 2023. 
 
You asked the Plan to pay for D0330 and D0340. You say that these should be processed as medically 
necessary. The Plan denied your request. The Plan says the denied 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 
panoramic radiographic images (D0330), and a 2D cephalometric radiographic image (D0340) provided on 
January 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that it is currently very painful to walk. The Plan 
denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6245) for tooth #6, #8, #9, and #10 and a 
retainer crown (D6740) for tooth #7, #11, and #12. 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has $5,000 of coverage and the 
requested dental services should go towards that. 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 the Plan pre-approved a pontic (D6245) for tooth #3 and #4 and a retainer crown (D6740) for tooth #2 
and #5 on July 23, 2023; therefore, the enrollees benefit for the requested items or services was exhausted on 
the date of approval of July 23, 2023. Therefore, we decided that the Plan does not have to pre-approve a pontic 
(D6245) for tooth #6, #8, #9, and #10 and a retainer crown (D6740) for tooth #7, #11, and #12.  
 
Your complaint about the Plans limitation of benefits 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: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for outpatient mental health services provided on January 
30, 2023, to March 30, 2023, by an out-of-network (OON) provider.  
 
 
 
 
 
 You asked the Plan to reimburse for outpatient mental health services. You say that you are requesting 
reimbursement for the services provided. The Plan denied your request. The Plan says the Point of Service 
(POS) option lets the enrollee use doctors and hospitals outside the plan provider network. The enrollee may 
receive all plan covered services from non-network providers, but the enrollee will have to pay a higher cost 
sharing that the one they pay when using in network providers. Please note that the POS benefit covers the 
United States and its territories. Providers rendering services under this option must be state-licensed or state 
certified. 
 
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 reimburse for care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to reimburse for these items/services. 
Therefore, we decided that the Plan does not have to reimburse for outpatient mental health services provided 
on January 30, 2023, to March 30, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #18, #19, #20, #21, #22, #26, #28, #30, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that the implants should be covered since you 
had the teeth removed. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all associated services 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 pre-approve the 
surgical placement of implant body (D6010) for tooth #18, #19, #20, #21, #22, #26, #28, #30, and #31.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140) 
provided on June 27, 2023. 
 
You asked the Plan to pay for the limited oral evaluation. The Plan denied your request. The Plan says your 
benefit for the limited oral evaluation 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 service was exhausted on dates of service March 1, 2023, and March 7, 
2023. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation - problem 
focused (D0140) provided on June 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, panoramic radiographic image, 
guided tissue regeneration, extraction, bone replacement graft, unspecified adjunctive procedure (D0140, 
D0330, D4266, D7210, D7953, D9999) provided on June 9, 2023, to June 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your 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 limited oral evaluation, 
panoramic radiographic image, guided tissue regeneration, extraction, bone replacement graft, unspecified 
adjunctive procedure (D0140, D0330, D4266, D7210, D7953, D9999) provided on June 9, 2023, to June 30, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on June 
6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with 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 date of service April 12, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for customized dentures (D5899) provided on April 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
customized dentures (D5899) provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve placement of an implanted loop recorder (ILR). 
 You asked the Plan to pre-approve the requested ILR procedure. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say ILR placement may be considered medically 
necessary when it is needed to evaluate syncope that is thought to be cardiac-related but occurs too infrequently 
to be detected by traditional external monitors.  
 
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 requested ILR procedure. Our 
reviewer says that the requested ILR procedure is not medically reasonable and necessary based on NCD 
criteria. Our physician reviewer found there is insufficient documentation to support the medical necessity for 
insertion of an ILR in this enrollees clinical management. 
 
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 requested ILR procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve placement of an implanted loop recorder (ILR).