Persius/hicric huggingface dataset:
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay reimbursement for an emergency room visit provided on May 
15, 2023. 
 
You asked the Plan to pay reimbursement for an emergency room visit. You say that you should be reimbursed 
the 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 $120 
copayment for emergency care.  
 
 
 
 You have been asked to pay a $120 copayment for an 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 pay reimbursement for an emergency room visit 
provided on May 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on June 16, 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 core 
buildup services (D2950) provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prefabricated abutment (D6056) for teeth numbers 8, 9, 
10 and 11, and implant supported crown (D6066) for teeth numbers 8, 9, 10 and 11. 
 
You asked the Plan to pre-approve prefabricated abutment (D6056) for teeth numbers 8, 9, 10 and 11, and 
implant supported crown (D6066) for teeth numbers 8, 9, 10 and 11. You say that you are appealing with 
supporting records. The Plan denied your request. The Plan says this is not covered under your 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 pre-approve 
prefabricated abutment (D6056) for teeth numbers 8, 9, 10 and 11, and implant supported crown (D6066) for 
teeth numbers 8, 9, 10 and 11.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) for tooth #7 
and #8 provided on April 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had an accident, and your teeth were 
extracted so the implants were medically necessary. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because dental implants are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body (D6010) for tooth #7 and #8 provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on March 30, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that after a decade of using the Plan's hearing 
network, you experienced ongoing issues with the hearing aids leading to problems with equilibrium and 
balance. You also say that in certain situations, especially when it comes to specialized medical equipment like 
hearing aids, patients might need to see services from out-of-network providers for various reasons. The Plan 
denied your request. The Plan says there is no coverage for hearing aids when received from a provider other 
than the Plan hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a 2D oral photographic image (D0350) provided on July 17, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you were examined by a dentist for a soft palate, 
and you want the Plan to cover the cost denied because it was not a tooth image. 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 2D oral photographic image (D0350) on July 17, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of July 17, 2023. Therefore, we decided that the 
Plan does not have to pay for a 2D oral photographic image (D0350) provided on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the resin-based composite (D2391) for 
tooth #30, #31, and #32 provided on June 28, 2023. 
 
You asked the Plan to waive the copayment for the dental services. You say that you went to the dentist for a 
root canal, but they did a filling instead and you should only been charged for 2 teeth. 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 each restorative service. The total copayment amount for all 3 resin-based composites (D2391) 
was $60 ($20 copayment x 3 resin-based composites). 
 
You have been asked to pay a $60 copayment for the 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 copayment for the resin-based composite 
(D2391) for tooth #30, #31, and #32 provided on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you never received dentures in 2019 and it was 
for a reline so the new dentures should be approved. The Plan denied your request. The Plan says your benefit 
for the requested items or services has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows the Plan paid for a complete upper denture (D5110) and a complete lower denture (D5120) on October 
24, 2019; therefore, your benefit for the requested items or services was exhausted on the date of service of 
October 24, 2019. Therefore, we decided that the Plan does not have to pay for a complete upper denture 
(D5110) and a complete lower denture (D5120) provided on June 8, 2023.  
 
Your complaint about what dental services the provider billed 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents via a controlled 
release vehicle into diseased crevicular tissue, per tooth (D4381) provided on July 24, 2023. 
 
You asked the Plan to pay for the localized delivery of antimicrobial agents. You say that when you went in for 
your teeth cleaning the hygienist only did half of your mouth and you were informed at check-out you owed 
$176. You also say that no one informed you before the procedure of any out-of-pocket expenses. The Plan 
denied your request. The Plan says there is no coverage for code D4381. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the localized 
delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 
(D4381) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids provided on May 27, 2023. 
 
You asked the Plan to pay for hearing aids. You say that you received a call from the Plan in which it was 
stated that there is coverage for hearing aids, and you were instructed to complete the reimbursement form. The 
Plan denied your request. The Plan says hearing aids ordered through providers other than the Plan hearing are 
not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan does not pay 
for hearing aids under this benefit.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
hearing aids provided on May 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for infrared therapy provided on July 31, 2023. 
 
You asked the Plan to pay for infrared therapy. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says that infrared therapy is excluded from Medicare coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that the use of infrared and/or near-infrared light and 
/or heat, including monochromatic infrared energy, is non covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of infrared therapy have not been met. Specifically, infrared therapy is not covered. Therefore, we 
decided that the Plan does not have to pay for infrared therapy provided on July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you had severe pain in your foot that prevented you 
from walking and the insert helped you perform daily living skills. 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair.  
 
You asked the Plan to pre-approve a shower chair. You say that you have a medical condition that prevents you 
from taking a normal bath, so the chair is medically necessary. The Plan denied your request. The Plan says 
this item is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for hearing aids provided on May 10, 2023. 
 
You asked the Plan to reimburse for hearing aids. You say that the wrong amount has been displayed on the 
Denial of Payment sent on June 20, 2023. The Plan denied your request. The Plan says the hearing benefit is 
not covered if the services are not registered in advance. The Plan also says that hearing aids ordered through 
providers other than the Plan hearing are not covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through an in-network Plan hearing provider and have 
prior authorization.  
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse for 
hearing aids provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard  hard appliance, partial arch (D9946) 
provided on June 5, 2023. 
 
You asked the Plan to pay for the occlusal guard. You say that you understand that it is not a covered expense 
but you have known for years that you bite down on your teeth when you sleep which now has caused a crack 
in your lower teeth. You also say that you really need the guard. The Plan denied your request. The Plan says 
there is no coverage for D9946 occlusal guard-hard appliance, partial arch. 
 
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 
occlusal guard  hard appliance, partial arch (D9946) provided on June 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on July 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that you could bring x-rays 
from your previous dentist instead of having the x-rays re-done with your new dentist. The Plan denied your 
request. The Plan says your benefit for the requested 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 service was exhausted on date of service October 26, 2022. Therefore, we 
decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on July 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) for tooth #9 provided 
on July 10, 2023. 
 
You asked the Plan to pay for the dental service. You say that your crown was dislodged when you fell, and it 
should not come under the frequency limitation category. 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 the re-cement or re-bond crown (D2920) for tooth #9 on September 21, 2022; 
therefore, your benefit for the requested item or service was exhausted on the date of service of September 21, 
2022. Therefore, we decided that the Plan does not have to pay for a re-cement or re-bond crown (D2920) for 
tooth #9 provided on July 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization. 
 
You asked the Plan to pre-approve genicular artery embolization. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 genicular artery embolization. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found this is considered an experimental procedure. It is the subject of ongoing 
clinical trials. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization have not been met. Therefore, we decided that the 
Plan does not have to pre-approve genicular artery embolization.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nursing facility care and the care management services 
provided on June 08, 2023. 
 
You asked the Plan to pay for the nursing facility care and the care management services. You say that you are 
requesting reconsideration of the denied claim. 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 nursing facility care 
and the care management services provided on June 08, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an injection provided on July 19, 2023. 
 
You asked the Plan to waive the coinsurance for an injection. You say that you have never paid for this service 
before and feel you should not be responsible for the coinsurance applied. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an injection. 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. You have been asked to pay $11.46, which is 20% of the allowed amount for a Medicare Part B 
drug injection ($57.28 allowed x 20% = $11.46). Therefore, we decided that the Plan does not have to waive 
the coinsurance for an injection provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6533. 
 
You asked the Plan to pre-approve this item. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested item is not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 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 pre-approve compression 
stockings identified with code A6533.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions (D7140 x 3) and surgical extractions (D7210 
x 5). 
 
You asked the Plan to pre-approve the dental services. You say that you have an unlimited extraction benefit 
for extractions necessary to fit the mouth for dentures. 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 authorization 202309076391872. 
Therefore, we decided that the Plan does not have to pre-approve extractions (D7140 x 3) and surgical 
extractions (D7210 x 5).