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 September 12, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were referred to the endodontist because you 
had an issue. 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 the Plan paid for a limited oral evaluation (D0140) on September 1, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of September 1, 2023. Therefore, we decided 
that the Plan does not have to pay for a limited oral evaluation (D0140) provided on September 12, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance treatment and response without transport 
services received on July 25, 2023. 
 
You asked the Plan to pay for the ambulance treatment and response without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there is 
no payable service. 
 
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 July 25, 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 the ambulance treatment and response without 
transport services received on July 25, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on March 15, 2023. 
 
You asked the Plan to pay for the lab services. You say that you were told that the issue would be resolved 
within 30 days, however after multiple verbal attempts to make the corrections it has not been done. The Plan 
denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 The enrollee ended Medicare Hospice benefits on March 10, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the lab services 
provided on March 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oxygen concentrator (E1390) and the unlisted special 
service (99199) provided on October 24, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the oxygen concentrator (E1390) and the unlisted special service (99199). You 
say that you have issues with your lungs and need the oxygen concentrator. The Plan denied your request. The 
Plan says the oxygen concentrator (E1390) and the unlisted special service (99199) is available in network. 
 
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 
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 the oxygen concentrator (E1390) and the unlisted 
special service (99199) provided on October 24, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
March 28, 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 the hearing aids 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 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 aids (V5298) purchased on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids (V5261) provided on January 30, 2023. 
 
You asked the Plan to reimburse for hearing aids (V5261). You say that a Plan representative told you that they 
would contact a couple of providers close by you and have them call you. You also say the providers never 
called you, so you went to the provider who responded quickly. The Plan denied your request. The Plan says 
the hearing benefit is not covered if the services are not registered in advance. The Plan also says that hearing 
aids ordered through providers other than the Plan hearing are not covered. 
 
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 you obtain the hearing aids through a Plan hearing network provider. We looked at this 
physician's review, the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids (V5261) have not been met. Therefore, we decided that the Plan does not have to 
reimburse for hearing aids (V5261) provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain or ceramic crown (D2740) and post and core in 
addition to crown (D2952) provided from May 24, 2023, to June 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are upset that you were not made aware that 
your Plan no longer covered out-of-network dental services. The Plan denied your request. The Plan says the 
dental services received from an out-of-network provider are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a porcelain or ceramic crown (D2740) and post and core in addition to crown (D2952) provided from 
May 24, 2023, to June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the reline of a complete maxillary denture (D5750) provided 
on July 24, 2023. 
 
You asked the Plan to pay for the reline of a complete maxillary denture. You say that you lost weight in the 
beginning of 2022, and needed to have your top dentures realigned to your new mouth positioning. You also 
say this service 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 May 24, 2023, when you 
received the maxillary tissue conditioning (D5850). Therefore, we decided that the Plan does not have to pay 
for the reline of a complete maxillary denture (D5750) provided on July 24, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit provided on April 18, 2023, 
by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ER visit. 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 were non-
emergent and prior authorization was not obtained. 
 
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 
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 emergency room (ER) visit provided on April 
18, 2023, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on July 8, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary but after treatment you did not feel that transport was necessary. The 
Plan denied your request. The Plan says without transport there are no payable services. 
 
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 July 8, 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 the ambulance response and treatment without 
transport services received on July 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the recement implant/abutment supported crown (D6092) 
provided on July 18, 2023. 
 
You asked the Plan to pay for the dental service. You say that your coverage includes implant crown repair, 
and your crown came loose so you had it repaired. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the recement implant/abutment supported crown 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 the 
recement implant/abutment supported crown (D6092) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140), and bone replacement graft for ridge preservation - per site (D7953) 
provided on August 10, 2023. 
 
You asked the Plan to pay for the extraction and bone replacement graft. You say that the provider told you the 
services would be covered by your insurance. You also say that you are requesting the plan help pay this bill. 
The Plan denied your request. The Plan says the services provided are not covered benefits 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140), and bone replacement graft for ridge 
preservation - per site (D7953) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an adult prophylaxis (D1110) provided on August 23, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that you received an approval letter dated June 
24, 2023, for a cleaning, radiographs, and oral evaluation for this provider. You also say that you visited that 
office on August 23, 2023, and were told you have a copayment of $68 since the provider is out-of-network. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for an adult prophylaxis (D1110) provided on 
August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on August 15, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the reason for needing another crown is your 
current crown broke off while eating dinner.  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 14, 2021. 
Therefore, we decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740) provided on 
August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) for tooth #3 
provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider said the previous crown needed to 
be replace because it was done incorrectly. 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 paid for a crown (D2740) and core buildup (D2950) for tooth #3 on November 8, 2018; 
therefore, your benefit for the requested items or services was exhausted on the date of service of November 8, 
2018. Therefore, we decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) 
for tooth #3 provided on August 9, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit provided on June 16, 2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit provided 
on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had issues finding the right provider, so the 
x-rays had to be redone. 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 15, 2023. 
Therefore, we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 
18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and reline complete 
mandibular denture (D5751) provided from August 16, 2023, to August 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told the provider accepts the 
insurance. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and reline 
complete mandibular denture (D5751) provided from August 16, 2023, to August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on June 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899) provided on July 28, 2023. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure. You say that you are 
requesting reconsideration stating the price of over $1,000 is excessive for you to have to pay to receive the 
lower false teeth already made in office. The Plan denied your request. The Plan says this service is not a 
covered expense 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
removable prosthodontic procedure, by report (D5899) provided on July 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2751) for tooth #18 provided on August 7, 
2023. 
 
You asked the Plan to pay more for the dental service. You say that the service should be covered because it 
should not matter what the least expensive option is. The Plan denied your request. The Plan says you are 
responsible for the difference in allowed amount and the proper cost share was applied. 
 
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 original allowed amount for the crown (D2750) was $1,027.50 and the total allowed amount for the 
approved crown (D2751) was $821.46 leaving a difference of $206.04 ($1,027.50 original allowed - $821.46 
approved allowed). The total coinsurance for the approved crown (D2751) was $410.73 ($821.46 approved 
allowed x 50% coinsurance). The total liability was $616.77 ($206.04 difference + $410.73 coinsurance). 
 
You have been asked to pay the difference between the allowed amount of the less expensive alternate 
procedure along with the coinsurance. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for a crown (D2751) for 
tooth #18 provided on August 7, 2023.