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

 
We decided that the Plan does not have to pay more for an extraction (D7140) for tooth #21, #24, #25, and #26 
provided by an out-of-network provider on April 10, 2023. 
  You asked the Plan to pay more for the dental services. You say that you have provided everything that is 
needed so the dental services would be covered. 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 total amount billed for 1 extraction (D7140) was $347 and the total allowed amount was $80 leaving a 
difference of $267 ($347 billed - $80 allowed). The total difference amount for all 4 extractions was $1,068 
($267 difference x 4 extractions). 
 
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 an extraction (D7140) for tooth #21, #24, 
#25, and #26 provided by an out-of-network provider on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 12, 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 date of service May 16, 2023. Therefore, 
we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) 
provided on June 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the surgical removal of erupted tooth (D7210) for tooth 
#1 and sedation (D9239) and to pay for a comprehensive oral evaluation (D0180) and the full mouth 
debridement (D4355) provided by an out-of-network provider on January 24, 2023, and February 14, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the provider was not in-
network and the services were an extreme emergency. 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. Your benefit for the comprehensive oral evaluation has already been 
exhausted. Also, the full mouth debridement 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. 
 
The total allowed billed for the extraction was $250 and the total allowed amount was $131 leaving a 
difference of $119 ($250 billed - $131 allowed). The total amount billed for the sedation was $325 and the total 
allowed amount was $264 leaving a difference of $61 ($325 billed - $264 allowed). 
 
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. The 
record shows the Plan paid for a comprehensive oral evaluation (D0150) on November 28, 2022; therefore, 
your benefit for the comprehensive oral evaluation was exhausted on the date of service of November 28, 2022. 
The full mouth debridement is not covered under the Plans dental benefit. Therefore, we decided that the Plan 
does not have to pay more for the surgical removal of erupted tooth (D7210) for tooth #1 and sedation (D9239) 
and to pay for a comprehensive oral evaluation (D0180) and the full mouth debridement (D4355) provided by 
an out-of-network provider on January 24, 2023, and February 14, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan.  
 
You asked the Plan to pre-approve the PET scan. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules state that a PET scan for dementia and neurodegenerative 
diseases are only covered under certain conditions. 
 
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 PET scan. Our reviewer says that 
the PET scan is not medically necessary. Our physician reviewer found there is no evidence that the scan is 
ordered as part of a trial or program as required by the NCD. In as much this service would not meet Medicare 
criteria for coverage based on the information provided. 
 
 
 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 PET scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a positron emission tomography (PET) scan.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the occlusal guard (D9944) provided on July 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that your provider says you have arthritis in your 
jaw and need the occlusal guard to prevent deterioration. 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 
occlusal guard (D9944) provided on July 12, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on May 
14, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are appealing the denied claim. 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 emergency 
department (ED) services provided on May 14, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment, no transport (A0998) 
provided on May 1, 2023. 
 
You asked the Plan to pay for ambulance response and treatment, no transport (A0998). You say that your 
daughter called for an ambulance. You also say you cannot pay the provider for that. The Plan denied your 
request. The Plan says since there was no transport, ambulance charges are not covered. The Plan also says that 
as per the provider, member refused transport 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on May 1, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment, no transport 
(A0998) provided on May 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 15, 2023, to May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe that these services 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 May 15, 2023, to May 31, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home or residence visit provided on May 3, 2023 by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for the home or residence visit. You say that we should not be penalized for 
providing medical services to the enrollee that were medically necessary. The Plan denied your request. The 
Plan says the out-of-network services were 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 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 the home or residence visit provided on May 3, 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 a panoramic x-ray (D0330) provided on May 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider stated they would not use an x-
ray more than one year old. You also say that because of the extraction of an infected tooth and an implant, the 
x-ray should be current. 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 23, 2021. 
Therefore, we decided that the Plan does not have to pay for a panoramic x-ray (D0330) provided on May 31, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation (D0180) provided 
on May 23, 2023. 
 
You asked the Plan to pay for D0180. You say that you believe the Plan should pay for this. The Plan denied 
your request. The Plan says the denied dental service is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
comprehensive periodontal evaluation (D0180) provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), comprehensive 
oral evaluation - new or established patient (D0150), prophylaxis - adult (D1110), and resin-based composite - 
two surfaces, anterior (D2331) provided on May 9, 2023, and May 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the $610.00 you paid to the 
dentist. 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 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 
panoramic radiographic image (D0330), comprehensive oral evaluation - new or established patient (D0150), 
prophylaxis - adult (D1110), and resin-based composite - two surfaces, anterior (D2331) provided on May 9, 
2023, and May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services should be paid. The Plan denied 
your request. The Plan says your annual dental allowance amount 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 June 27, 2023. Therefore, 
we decided that the Plan does not have to pay the remaining amount for dental services provided on June 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), the panoramic 
radiographic image (D0330), and the full mouth debridement (D4355) provided on May 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went to a new provider and they prefer to 
do their own x-rays regardless if you had them already done. The Plan denied your request. The Plan says your 
benefit for the comprehensive oral evaluation and panoramic radiographic image has already been exhausted. 
Also, the full mouth debridement 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, certain limitations apply. The record 
shows the Plan paid for a comprehensive oral evaluation (D0150) on July 6, 2022; therefore, your benefit for 
the comprehensive oral evaluation was exhausted on the date of service of July 6, 2022. The record also shows 
the Plan paid for the intraoral complete series (D0210) on May 15, 2023; therefore, your benefit for the 
panoramic radiographic image was exhausted on the date of service of May 15, 2023. The full mouth 
debridement is not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have 
to pay for a comprehensive oral evaluation (D0150), the panoramic radiographic image (D0330), and the full 
mouth debridement (D4355) provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you went for a normal cleaning, and these 
services should be paid. 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 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination and an ophthalmoscopy provided 
on March 06, 2023. 
 
You asked the Plan to pay for a medical eye examination and an ophthalmoscopy. You say that a provider 
performing services in a nursing home facility is not responsible to obtain authorization. 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 a medical eye 
examination and an ophthalmoscopy provided on March 06, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the enrollee 
to be able to regain their strength and walk again. The Plan denied your request. The Plan says the enrollee 
does not meet the criteria for admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three crowns (D2740) provided on June 14, 2023. 
 
You asked the Plan to pay for three crowns. You say that you fell and broke your teeth, and this was necessary. 
The Plan denied your request. The Plan says this is not a covered 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. 
 
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 three 
crowns (D2740) provided on June 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Camzyos. 
 
You asked the Plan to pre-approve Camzyos. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the request for Camzyos cannot be approved at this time. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Camzyos. Our reviewer says that the 
medication is not medically necessary. Our physician reviewer found the Food and Drug Administration has 
not stated that the requested drug Camzyos is indicated for the enrollee's condition. The Medicare approved 
drug compendia does not contain a supportive citation for the use of the requested drug in the enrollee's clinical 
situation. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Camzyos have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Camzyos.