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

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #18 and #20, a pontic 
(D6240) for tooth #19, and a retainer crown (D6750) for tooth #18 and #20 provided on May 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting reimbursement for the dental 
procedures. The Plan denied your request. The Plan says your dental maximum benefit for the year 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 $1,250 for dental services on April 28, 2023; therefore, your dental maximum benefit for 
the year of 2023 was exhausted on the date of service of April 28, 2023. Therefore, we decided that the Plan 
does not have to pay for the core buildup (D2950) for tooth #18 and #20, a pontic (D6240) for tooth #19, and a 
retainer crown (D6750) for tooth #18 and #20 provided on May 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care, and related services 
provided on July 19, 2023, to August 01, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care, and related services. You say that these services 
were medically necessary. 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 subsequent nursing 
facility care, and related services provided on July 19, 2023, to August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for practitioner services provided on April 12, 2023. 
 
You asked the Plan to pay for practitioner services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says the provider does not bill Group Health Plan first; 
Medicare may not pay conditionally on the liability. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Medicare 
guidance says if there is a primary Group Health Plan (GHP) and the provider does not bill the GHP first, 
Medicare may not pay conditionally on the liability (including self-insurance). Providers must bill the GHP 
before billing Medicare, and the primary payer payment information that appears on all primary payer 
remittance advices must appear on the claim submitted to Medicare. As the secondary insurer, the Plan cannot 
be held responsible for practitioner services until the primary insurer has denied the claim for these services. 
Therefore, we decided that the Plan does not have to pay for practitioner services provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a recement or re-bond crown (D2920) for tooth #18 provided 
on July 25, 2023. 
 
You asked the Plan to pay for the dental service. You say that the procedure was needed because the crown fell 
off twice and you had the option for a new crown, but it would have cost more. 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 recement or re-bond crown (D2920) for tooth #18 on April 24, 2023; therefore, your 
benefit for the requested item or service was exhausted on the date of service of April 24, 2023. Therefore, we 
decided that the Plan does not have to pay for a recement or re-bond crown (D2920) for tooth #18 provided on 
July 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sphere, trifocal lenses (V2300) provided on August 21, 2023.  
You asked the Plan to pay for sphere, trifocal lenses (V2300). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says this provider is not a participating provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the vision services are obtained through a Plan vision care 
provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that vision services must be provided by a 
contracted provider. Based on this information, we decided that the Plan's rules for coverage of sphere, trifocal 
lenses (V2300) have not been met. Therefore, we decided that the Plan does not have to pay for sphere, trifocal 
lenses (V2300) provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the office visit on August 16, 2023. 
 
You asked the Plan to waive the deductible for the office visit. You say that you cannot pay this bill and would 
not have agreed to the terms. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctor's office visits.  
 
The item or service you asked the Plan to waive the deductible for falls within the physician/practitioner 
services, including doctor's office visits benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $1,000 deductible which applies to physician/practitioner services, 
including doctor's office visits. This cost sharing is a contractual obligation that had not been met at the time 
the office visit was received on August 16, 2023. Therefore, we decided that the Plan does not have to waive 
the deductible for the office visit on August 16, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a new primary care office visit provided on April 25, 2023. 
 
You asked the Plan to pay for a new primary care office visit. You say that you double checked both with the 
Plan and the office to make sure they were in-network. 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 new primary care 
office visit provided on April 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anesthesiology services provided on August 01, 2023. 
 You asked the Plan to pay for the anesthesiology services. You say that you are asking for the review for the 
submitted documents. 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 the anesthesiology 
services provided on August 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on August 28, 2023. 
 
You asked the Plan to pay for an office visit. You say that this was medically necessary and should be covered. 
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 an office visit provided 
on August 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an alarm system (A9280). 
 
You asked the Plan to pre-approve the alarm system. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve an alarm system (A9280).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical additional radiographic image 
(D0230) and the adjunctive pre-diagnostic test (D0431) provided on August 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the intraoral x-ray 
provided has already been exhausted. Additionally, an adjunctive pre-diagnostic test is not covered under the 
supplemental dental policy.  
 
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 intraoral x-ray provided was exhausted on date of service August 14, 2023.  
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. On this day, you 
received two intraoral x-rays, in which one was paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for this service. Additionally, an adjunctive pre-diagnostic test is not covered under the 
supplemental dental policy. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical additional radiographic image (D0230) and the adjunctive pre-diagnostic test (D0431) provided on 
August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on September 
13, 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 27, 2019. 
Therefore, we decided that the Plan does not have to pay for mandibular partial denture (D5214) provided on 
September 13, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance a nivolumab injection provided on January 
27, 2022. 
 
You asked the Plan to waive the coinsurance the medication. You say that you met your maximum out-of-
pocket. 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 20% 
coinsurance for Medicare Part B prescription drugs.  
 The records show that as of January 27, 2022, you have $1,233.49 remaining to meet your out-of-pocket 
amount. Therefore, you only owe this amount for the medication, which is less than the 20% coinsurance 
($14,037.60 allowed amount x 20% = $2,807.52). This item/service falls within the Medicare Part B 
prescription drugs 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 a nivolumab injection 
provided on January 27, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on May 18, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you are sending medical records to be reviewed. 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 the lab testing provided 
on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and to pay for the core buildup 
(D2950) for tooth #19 provided on July 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the provider assured you that the Plan 
would cover the dental services and you would have waited to get the crown if it was not going to be covered. 
The Plan denied your request. The Plan says your dental maximum benefit for the year 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 $1,410 for dental services on January 12, 2023. On March 7, 2023, the Plan paid $951 for 
dental services. On April 11, 2023, the Plan paid $1,592 for dental services. On June 2, 2023, the Plan paid 
$1,294 for dental services. On July 12, 2023, the Plan paid $753 for dental services. For the year of 2023 the 
Plan paid $6,000 ($1,410 paid + $951 paid + $1,592 paid + $1,294 paid + $753 paid) for dental services; 
therefore, your dental maximum benefit for the year of 2023 exhausted on the date of service of July 12, 2023. 
Therefore, we decided that the Plan does not have to pay more for a crown (D2740) and to pay for the core 
buildup (D2950) for tooth #19 provided on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for periodontal scaling and root planning 
(D4342) and topical application of fluoride varnish (D1206) provided on July 25, 2023. 
 
You asked the Plan to waive the cost share for these dental services. You say that this should be covered. 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 50% 
coinsurance for dental services and a $10 copayment per visit for all non-Medicare covered services.  
 
You have been asked to pay 50% coinsurance and a $10 copayment for these 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 cost share for periodontal 
scaling and root planning (D4342) and topical application of fluoride varnish (D1206) provided on July 25, 
2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport (A0998) 
provided on May 29, 2023. 
 
You asked the Plan to pay for ambulance response and treatment with no transport (A0998). You say that you 
are trying to dispute a charge due to a claim that was denied. The Plan denied your request. The Plan says non-
transportation by ambulance is not a covered benefit. 
 
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 29, 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 with no 
transport (A0998) provided on May 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 15, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the office visit. You say that you provider told you that they would take care of 
the denied service. The Plan denied your request. The Plan says no prior authorization was 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 did not pre-approve the 
office visit. We found no exception that would require the Plan to pay for the office visit.  Therefore, we decided that the Plan does not have to pay for the office visit provided on May 15, 2023, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for eyewear insurance and taxes for the insurance 
provided on July 11, 2023. 
 
You asked the Plan to reimburse for eyewear insurance and taxes for the insurance. You say that you are still 
waiting for the reimbursement. The Plan denied your request. The Plan says this is not a covered benefit. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers up to $200 towards the cost of routine eyewear. Eyewear insurance and taxes are 
excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $200 allowance toward the cost or 
routine contact lenses or eyewear every year from the Plan and non-Plan providers. The Plan rules also say that 
eyewear does not include polish and insurance. Sales tax is also not covered by Medicare or the Plan.  Based on 
this information, we decided that the Plan's rules for coverage of eyewear insurance and taxes for the insurance 
have not been met. Therefore, we decided that the Plan does not have to reimburse for eyewear insurance and 
taxes for the insurance provided on July 11, 2023.  
 
Your complaint about the Plan potentially not reimbursing you for approved services 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.