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

 
We decided that the Plan does not have to pay for the root canals (D3330) on teeth #s 19, 20, 30 and the crown 
(D2740) on tooth #30 provided on June 1, 2023, to July 3, 2023. 
 
You asked the Plan to pay for the core build-ups (D2950) on teeth #s 19, 20, 30. You say that you needed to 
submit all necessary paperwork from root canals and would like to appeal your payments. The Plan denied 
your request. The Plan says the services are not covered 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 root 
canals (D3330) on teeth #s 19, 20, 30 and the crown (D2740) on tooth #30 provided on June 1, 2023, to July 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an adult prophylaxis (D1110) provided on 
July 27, 2023. 
 
You asked the Plan to waive the coinsurance for an adult prophylaxis (D1110). You say that you did not realize 
that your provider was out-of-network. You also say you are broke, and do not have money to be paying them. 
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 the total allowed amount for all routine (preventive and comprehensive) dental services.  
 
 You have been asked to pay $52 in coinsurance, which is 50% of the allowed amount for an adult prophylaxis 
(D1110). This item/service falls within the total allowed amount for all routine (preventive and comprehensive) 
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 coinsurance for an adult prophylaxis 
(D1110) provided on July 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for incisional biopsy of oral tissue-soft (D7286), guided 
tissue regeneration (D4266), bone replacement graft (D4263), and apicoectomy (D3425) provided on July 13, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that these services should have been covered, 
if not under the dental Plan, then under the medical Plan. 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 for incisional biopsy of oral tissue-soft (D7286). This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. Guided tissue regeneration (D4266), bone replacement graft 
(D4263), and apicoectomy (D3425) are not a covered benefit under your Plan. Therefore, we decided that the 
Plan does not have to pay more for incisional biopsy of oral tissue-soft (D7286), guided tissue regeneration 
(D4266), bone replacement graft (D4263), and apicoectomy (D3425) provided on July 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox solution. 
 You asked the Plan to pre-approve Botox solution. 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. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Botox solution. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the provided records do not indicate 
that the enrollee has tried and failed the plan's preferred step one alternative. The record does not indicate that 
the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one 
alternative. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox solution have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox solution.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided on August 30, 
2023. 
 
You asked the Plan to pay for D1330. You say that you feel like it is reasonable for the Plan to pay for this. The 
Plan denied your request. The Plan says the denied dental 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 oral 
hygiene instructions (D1330) provided on August 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6530 that 
were issued on July 9, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that due to a prior blood clot several years 
ago in your leg, and also the fact that now for the last couple years you are on blood pressure medication. You 
also say that your primary care physician has requested you continue to wear compression stockings. The Plan 
denied your request. The Plan says this is not a covered service.  
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6530 that were issued on July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the maxillary partial denture - cast metal framework 
with resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin denture 
bases  (D5214) provided on July 12, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you received a denial of payment due to 
the remaining amount owed is over the annual maximum of $2,500. You also say that you cannot pay because 
you are on a fixed income. The Plan denied your request. The Plan says your benefit for the dental services 
$2,500 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 your benefit for the requested services was exhausted on dates of service June 29, 2023 and July 12, 
2023. The Plan has provided evidence of having made payments totaling $2,500 towards the cost of dental 
services in 2023. This included a partial payment of $109 towards the mandibular partial denture. Therefore, 
we decided that the Plan does not have to pay more for the maxillary partial denture - cast metal framework 
with resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin denture 
bases  (D5214) provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 receiver and sensor.  
You asked the Plan to pre-approve a continuous glucose monitor (CGM). You say that you would like the Plan 
to approve this. The Plan denied your request. The Plan says the enrollee has not met the medical criteria 
needed for a CGM. 
 
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 continuous glucose monitor (CGM) have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a Dexcom G7 receiver and sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction and bone replacement graft (D7210, D7953) 
provided on June 20, 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 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 18, 2023. Therefore, 
we decided that the Plan does not have to pay for an extraction and bone replacement graft (D7210, D7953) 
provided on June 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on July 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that an employee of the Plan sent you to this 
provider, made the appointment and guaranteed that the provider would be paid.  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 Plan's 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 January 30, 2019. 
Therefore, we decided that the Plan does not have to pay for panoramic x-ray (D0330) provided on July 7, 
2023.  
 
Your complaint about potentially being lied to by an employee of the Plan 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the diabetic shoes (A5500) and inserts (A5514). 
 
You asked the Plan to pre-approve the diabetic shoes and inserts. You say that you would like the items 
approved and covered. The Plan denied your request. The Plan says the services requested 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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the diabetic shoes (A5500) and inserts (A5514).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor on August 24, 
2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the evaluation portion of the visit was 
necessary for the doctor and should be covered. The Plan denied your request. The Plan says this chiropractic 
service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor on August 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - three surfaces, anterior (D2332), 
provided on July 11, 2023. We also decided that the Plan does not have to pay more for the limited oral 
evaluation - problem focused (D0140), intraoral - periapical first radiographic image (D0220) provided on July 
11, 2023. 
 You asked the Plan to pay for the resin-based composite. You also asked the Plan to pay more for the limited 
oral evaluation - problem focused and the intraoral - periapical first radiographic image. You say that you were 
not satisfied with the procedures provided so you decided to attend another dentist. The Plan denied your 
request. The Plan says your benefit for the resin-based composite - three surfaces, anterior has already been 
exhausted. The Plan also 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite - three surfaces, anterior was exhausted on date of service 
June 16 2023. Therefore, we decided that the Plan does not have to pay for the resin-based composite - three 
surfaces, anterior (D2332), provided on July 11, 2023.  
 
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 limited oral evaluation - problem focused 
(D0140), intraoral - periapical first radiographic image (D0220) provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 test kits provided on September 
19, 2023. 
 
You asked the Plan to pay for over-the-counter COVID-19 test kits. You say that you were under the 
impression that this would be covered. You also say that had you been advised the OTC COVID-19 testing was 
no longer covered being June 1, 2023, you never would have taken the time to submit this claim. The Plan 
denied your request. The Plan says over the counter (OTC) COVID-19 tests are not covered by Medicare after 
May 11, 2023. 
 The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and over-the-
counter COVID-19 test kits is an OTC item. Although the Plan offers and OTC benefit, COVID-19 test kits are 
not covered by this benefit. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of over-the-counter COVID-19 test kits have not been met. Therefore, we decided that the Plan does 
not have to pay for over-the-counter COVID-19 test kits provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for porcelain or ceramic retainer crown (D6740) for teeth 
numbers 18 and 21, and porcelain or ceramic pontic (D6245) for tooth 20 provided on June 26, 2023, to August 
23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you feel that the bridge replacement should be 
shown as treatment, incurred and billed, in July and August of 2023, after your benefits were increased. You 
also say that the provider's office has refused to correct 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 maximum benefit allowed was exhausted for the requested items or services on date of service 
August 23, 2023. Therefore, we decided that the Plan does not have to pay for porcelain or ceramic retainer 
crown (D6740) for teeth numbers 18 and 21, and porcelain or ceramic pontic (D6245) for tooth 20 provided on 
June 26, 2023, to August 23, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on April 24, 2023. 
 
You asked the Plan to pay for psychotherapy. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the health Plan requires utilization of network providers when possible and 
available and requires authorization for certain services. No medical necessity for an out-of-network provider, 
such as an urgent or emergency situation, has been documented. 
 
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 
service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for psychotherapy provided on April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the telephone evaluation and management 
service and the dilated retinal eye examination provided on May 9, 2023. 
 
You asked the Plan to waive the copayment for the telephone evaluation and management service and the 
dilated retinal eye examination. You say that the provider initially billed you $85, and you now received a 
second bill for $35. 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 Medicare -covered vision services at an in-network specialist's office.  
 
 You have been asked to pay a $35 copayment for the telephone evaluation and management service and the 
dilated retinal eye examination. This item/service falls within the vision 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 telephone evaluation and management service and the dilated 
retinal eye examination provided on May 9, 2023. 
 
Please note, the providers office showed that you have already paid $35 and as of October 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on July 19, 2023.  
 
You asked the Plan to pay for foot orthotics. You say that you would like reconsideration because the requested 
foot orthotics are medically necessary. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics provided on July 19, 
2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for surgery at an outpatient hospital provided 
on April 24, 2023. 
 
You asked the Plan to waive the coinsurance for surgery at an outpatient hospital. You say that you have not 
received bills this high before. 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 25% 
coinsurance for surgical services at an outpatient hospital. 
 
 You have been asked to pay 25% coinsurance for surgery at an outpatient hospital. This item/service falls 
within the surgical services at an outpatient hospital 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. Please note that this coinsurance bill exhausts your 2023 out-of-
pocket maximum, which is why you are being charged the lesser amount of $5633.97 rather than the full 25% 
coinsurance for this surgery. Therefore, we decided that the Plan does not have to waive the coinsurance for 
surgery at an outpatient hospital provided on April 24, 2023.