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 - problem focused (D0140) 
provided on December 30, 2022. 
 
You asked the Plan to pay for the dental services. You say that you pay extra for the dental and the plan should 
cover this. The Plan denied your request. The Plan says your benefit for the requested item or service has 
already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the limited oral evaluation - problem focused was exhausted on date of service May 18, 
2022.  Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on December 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for sinus augmentation via a vertical approach (D7952), surgical 
placement of implant body (D6010), custom fabricated abutment (D6057) and abutment supported porcelain 
fused to metal crown (D6059) provided on March 1, 2022, to July 19, 2022. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. 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 sinus 
augmentation via a vertical approach (D7952), surgical placement of implant body (D6010), custom fabricated abutment (D6057) and abutment supported porcelain fused to metal crown (D6059) provided on March 1, 
2022, to July 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 1, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that treatment 
was provided by the emergency medical services to the point where it wasn't necessary to transport because the 
glucose levels had stabilized. The Plan denied your request. The Plan says these services are 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 December 1, 2022. 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 with no 
transport provided on December 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the re-cement or re-bond of a crown (D2920) provided on 
February 15, 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 the re-
cement or re-bond of a crown (D2920) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for a periodic oral exam, bitewing x-rays, and 
cleaning (D0120, D0274, D1110) provided on November 16, 2021. 
 
You asked the Plan to reimburse payment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the services denied correctly as 
the claim was filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until December 27, 2022. This means that 
more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to reimburse payment for a periodic oral exam, bitewing x-rays, and 
cleaning (D0120, D0274, D1110) provided on November 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on December 20, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like the Plan to 
reconsider their denial of payment. The Plan denied your request. The Plan says Medicare does not separately 
pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
December 20, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the podiatry services provided on January 
11, 2023. 
 
You asked the Plan to reduce the copayment for the podiatry services. You say that you do not understand why 
you have to pay $70 in addition to the $35 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 $35 
copayment for podiatry services. 
 
You have been asked to pay a $35 copayment for the podiatry services. This item/service falls within the 
podiatry 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 reduce the copayment for the podiatry services 
provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical placement of implant body: endosteal implant 
(D6010), bone graft at time of implant placement (D6104), and cone beam CT capture and interpretation with 
field of view of both jaws; with or without cranium (D0367) provided on January 24, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D6010, D6104 and D0367. You say that 
the service was done to allow you to chew your food and not for cosmetic purposes. You also say that you were 
under the impression that you had a $1,500.00 allowance for such procedures. The Plan denied your request. 
The Plan says these services are not covered under the benefit package.  
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 surgical 
placement of implant body: endosteal implant (D6010), bone graft at time of implant placement (D6104), and 
cone beam CT capture and interpretation with field of view of both jaws; with or without cranium (D0367) 
provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of x-ray images (D0210), panoramic x-ray (D0330), adjunctive pre-diagnostic test that aids in detection of 
mucosal abnormalities (D0431) and core buildups (D2950 x 2) provided from February 09, 2023, to February 
20, 2023. 
 You asked the Plan to pay for the dental services. You say that these are covered dental benefits. The Plan 
denied your request. The Plan says these services are either not a covered benefit under your dental plan or the 
benefit has 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 items or services was exhausted on date of service April 4, 2022. 
Additionally, D0431 and D2950 are not covered under any circumstance. Therefore, we decided that the Plan 
does not have to pay for the comprehensive oral evaluation (D0150), complete series of x-ray images (D0210), 
panoramic x-ray (D0330), adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities 
(D0431) and core buildups (D2950 x 2) provided from February 09, 2023, to February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention services and suturing of recent small wounds 
(D2951, D7910) provided on March 29, 2022. 
 
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 pin 
retention services and suturing of recent small wounds (D2951, D7910) provided on March 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-rays, and bitewing x-
rays (D0140, D0270, D0220) provided on March 18, 2022. 
 
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 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 a limited oral evaluation, intraoral x-rays, and bitewing x-rays (D0140, D0270, D0220) provided on 
March 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), provided on December 29, 
2022. 
 
You asked the Plan to pay for D0140. You say that you do not know how you could have already exceeded the 
limit for these services. The Plan denied your request. The Plan says D0140 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 a limited 
oral evaluation (D0140), provided on December 29, 2022. 
 
Please note that a radiographic image (D0220), and bitewings (D0270) have already been approved.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on January 20, 
2023, to January 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services 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 subsequent nursing 
facility care provided on January 20, 2023, to January 24, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM) 
system. 
 
You asked the Plan to pre-approve a Dexcom G7 CGM system. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a Dexcom G7 CGM system have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a Dexcom G7 continuous glucose monitor (CGM) system.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve interim crowns (D2799 x 4). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial because you 
need these procedures. 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 pre-approve 
interim crowns (D2799 x 4).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on April 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance did arrive but you were not transported as the medics were able to help you at the scene. The Plan 
denied your request. The Plan says these services are 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 April 14, 2022. 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 with no 
transport provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture - flexible base (5225), and 
mandibular partial denture  - flexible base (D5226) provided on January 25, 2023. 
 
You asked the Plan to pay for the maxillary and mandibular partial dentures. You say that a predetermination 
was complete so you believed a portion of the cost would be covered. You also say that you were not aware 
that your plan had changed and that you no longer had coverage for the services. The Plan denied your request. 
The Plan says we reviewed your contact history and confirmed that the Annual Notice of Changes was sent to 
you on September 21, 2022 and specified that your current dental plan would not be available in 2023. 
Additionally, a complete breakdown of the covered benefits was included with the notice. 
 
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 
maxillary partial denture - flexible base (5225), and mandibular partial denture  - flexible base (D5226) 
provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction (D7210), bone replacement graft (D7953), guided 
tissue regeneration (D4266) and a consultation (D9310) provided on October 7, 2022. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. 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 extraction 
(D7210), bone replacement graft (D7953), guided tissue regeneration (D4266) and a consultation (D9310) 
provided on October 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the electrocardiogram (EKG) provided on 
January 10, 2023. 
 
You asked the Plan to waive the copayment for the electrocardiogram (EKG). You say that you want to know 
why this was not covered by the Plan. 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 
copayment for outpatient diagnostic tests, including EKGs. 
 
You have been asked to pay a $20 copayment for the electrocardiogram (EKG). This item/service falls within 
the outpatient diagnostic tests, including EKGs 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. However, since the allowed amount is less than the standard 
copayment, you only owe $15.85. Therefore, we decided that the Plan does not have to waive the copayment 
for the electrocardiogram (EKG) provided on January 10, 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 scan is needed for post-op surveillance. The 
Plan denied your request. The Plan says the request does not meet Medicare guidelines for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 a 
PET scan is not medically necessary. Our physician reviewer found PET scans are not indicated for 
surveillance based on Medicare guidelines. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room visit provided on 
January 18, 2023. 
 
You asked the Plan to waive the copayment for the emergency room visit. You say that you went to the 
emergency room due to a faulty test from your doctor, and do not feel you should have to pay. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for the emergency room visit. This item/service falls within the 
emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan. Therefore, we decided that the Plan does not have to waive the copayment for the emergency room visit 
provided on January 18, 2023.