Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable Group 1 power wheelchair. 
 
You asked the Plan to pre-approve a portable power wheelchair. You say that you need a wheelchair as soon as 
possible. You say that your current chair does not work well. You also say that you cannot stand or go to your 
local supermarket. The Plan denied your request. The Plan says no power wheelchair evaluation has been 
completed. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
The file shows that your condition can be improved by a walker, cane or manual wheelchair. This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to 
pre-approve a portable Group 1 power wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015) received on September 13, 2023. 
 You asked the Plan to pay for an eye refraction. You say that this should be covered. The Plan denied your 
request. The Plan says the service at issue is not a covered benefit when performed during a medical eye 
examination. 
 
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. 
 
We looked at the file and the Plan's rules.  Based on this information, we decided that the Plan's rules for 
coverage of an eye refraction have not been met. Specifically, eye refraction is only covered by the Plan when 
it is performed as part of a routine screening by a participating provider. This service was performed for 
medical vision purposes, and therefore is not a covered benefit. Therefore, we decided that the Plan does not 
have to pay for an eye refraction (92015) received on September 13, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for provision of test materials and equipment for home 
monitoring (G0249) provided on July 27, 2023. 
 
You asked the Plan to pay for provision of test materials and equipment for home monitoring (G0249). You say 
that you want the Plan to pay for the service 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 provision of test 
materials and equipment for home monitoring (G0249) provided on July 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on August 
4, 2023. 
 
You asked the Plan to pay for the ED services. You say that you have provided the medical documentation. 
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 August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided 
on March 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dental procedure was included in your 
surgery and all the procedures were medically necessary. The Plan denied your request. The Plan says your 
annual 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 $293 for dental services on February 9, 2023. On March 16, 2023, the Plan paid $1,529 for 
dental services. On August 8, 2023, the Plan paid $178 for dental services. For the year of 2023 the Plan paid 
$2,000 ($293 paid + $1,529 paid + $178 paid) for dental services; therefore, your annual dental maximum 
benefit for the year of 2023 was exhausted on the date of service of  August 8, 2023. Therefore, we decided 
that the Plan does not have to pay for the primary closure of a sinus perforation (D7261) provided on March 16, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210), deep sedation/general anesthesia-first 15 minutes (D9222), and the deep 
sedation/general anesthesia-each subsequent 15 minute increment (D9223) provided on August 29, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the services provided are 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, the services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extraction, of 
an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210), deep sedation/general 
anesthesia-first 15 minutes (D9222), and the deep sedation/general anesthesia-each subsequent 15 minute 
increment (D9223) provided on August 29, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
November 2, 2022. 
 You asked the Plan to pay for the ED services. You say that you would like to request reconsideration for 
payment. 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. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on November 
2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on August 21, 2023. 
 
You asked the Plan to pay for the extraction. You say that you have submitted records of the dental work that 
has been paid for by you and the dental insurance. You also say that hopefully you will consider some of the 
work done. The Plan denied your request. The Plan says your benefit for the requested service $1,500 dollar 
limit was met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.  
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows that the Plan paid $1,500 under claim number ending in 00871 for date of service March 10, 2023. 
Therefore, we decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) provided on August 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), dental 
cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) provided on August 17, 2023. 
 
You asked the Plan to pay more 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 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 the comprehensive oral evaluation (D0150), 
dental cleaning (D1110), and the bitewing x-rays-four radiographic images (D0274) provided on August 17, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140), the intraoral 
radiographic image (D0220), and an extraction (D7140) for tooth #24 provided on September 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that the representative told you that the extraction 
was covered, and you are appealing the denial. The Plan denied your request. The Plan says the denial of 
payment for these services is correct because the limited oral evaluation, the intraoral radiographic image, and 
the extraction are not covered by the Plan. Also, it was verified that you were told the proper benefits prior to 
the date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 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 
limited oral evaluation (D0140), the intraoral radiographic image (D0220), and an extraction (D7140) for tooth 
#24 provided on September 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D7320 and D6010) on July 5, 2023. 
 
You asked the Plan to pay for the dental services (D7320 and D6010). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the dental services were received 
from an out-of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the dental services (D7320 and D6010) on July 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported porcelain/ceramic crown (D6058) 
provided on September 19, 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 an 
abutment supported porcelain/ceramic crown (D6058) provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crowns - porcelain/ceramic (D2740) provided on 
June 13, 2023. 
 
You asked the Plan to pay more for the crowns. You say that you had mouth cancer surgery and they had to 
remove the teeth to get to the bone cancer. 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 crowns - resin-based composite or porcelain/ceramic when provided out-of-network. You have been asked to pay a 50% for the crowns. The crowns were received from an out-of-network provider. 
This service falls within the dental services restorative 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 pay 
more for the crowns - porcelain/ceramic (D2740) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue additional payment for the periodontal scaling and root 
planing-four or more teeth per quadrant (D4341) provided on August 14, 2023 and August 15, 2023. 
 
You asked the Plan to issue additional payment for these 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 services provided 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 services provided was exhausted on August 14, 2023.  
  
 
 
Specifically, the Plans contract states that the annual maximum dental benefit is $500. The Plan previously 
issued payments in the total amount of $500 ($398 + $102) for dental services provided in the 2023 calendar 
year. Therefore, you have exhausted the allowable benefit for the services provided in this case. Therefore, we 
decided that the Plan does not have to issue additional payment for the periodontal scaling and root planing-
four or more teeth per quadrant (D4341) provided on August 14, 2023 and August 15, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an echocardiogram (93306) provided on August 21, 2023. 
 
You asked the Plan to pay for an echocardiogram (93306). You say that you want the Plan to pay for this 
service 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 echocardiogram 
(93306) provided on August 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on July 6, 2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that this was a routine eye exam and 
there should be a $0 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 (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment per visit for Medicare-covered exams to diagnose and treat diseases of the eye.  
 
 You have been asked to pay a $40 copayment for the office vision. The office visit falls within the vision care 
benefit category. The medical record shows a diagnosis of hypertensive retinopathy which makes the office 
visit medical in nature. 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 the office visit provided on July 
6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the pontic - porcelain/ceramic (D6245), and retainer 
crowns - porcelain/ceramic (D6740) provided on July 31, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the bridge was a three-unit bridge to 
replace tooth number 29 which was not congenitally missing. The Plan denied your request. The Plan says the 
benefit for the requested services $2,000 dollar limit was met. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
provided evidence of having made payments totaling $2000 towards the cost of dental services provided in 
2023. Therefore, we decided that the Plan does not have to pay more for the pontic - porcelain/ceramic 
(D6245), and retainer crowns - porcelain/ceramic (D6740) provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for orthodontic retention services (D8680) provided on 
August 29, 2023. 
 
You asked the Plan to pay more 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 August 29, 2023. 
Therefore, we decided that the Plan does not have to pay more for orthodontic retention services (D8680) 
provided on August 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for alveoloplasty (D7311) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 27, 2023. 
Therefore, we decided that the Plan does not have to pay for alveoloplasty (D7311) provided on August 10, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0150, D0210, and D1110) on 
September 20, 2023. 
 
You asked the Plan to pay for the dental services (D0150, D0210, and D1110). You say that you would like to 
request reconsideration for payment. 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 19, 2023. Therefore, we decided that the Plan does not have to pay for the dental services (D0150, D0210, and D1110) on 
September 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D2740) on August 22, 2023. 
 
You asked the Plan to pay for the dental service (D2740). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the 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 the dental 
service (D2740) on August 22, 2023.