Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 26, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 26, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on August 15, 2023. 
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration for 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 home health services 
provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that if you continue to walk on your leg it may 
cause tissue damage. You say that your leg may need to be amputated. You also say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 power scooter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 
19, 2023. 
 
You asked the Plan to pay for the dental service. You say that the exam is part of your checkup and you have 
$1,000 to spend each year. 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 periodic oral evaluation (D0120) on May 10, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of May 10, 2023. Therefore, we decided that the 
Plan does not have to pay for a periodic oral evaluation (D0120) provided on September 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), intraoral-
comprehensive series of radiographic images (D0210), dental cleaning (D1110), panoramic radiographic image 
(D0330), and the unspecified diagnostic procedure, by report (D0999) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says 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 dental services from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/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 
comprehensive oral evaluation (D0150), intraoral-comprehensive series of radiographic images (D0210), 
dental cleaning (D1110), panoramic radiographic image (D0330), and the unspecified diagnostic procedure, by 
report (D0999) provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) 
provided on July 21, 2023. 
 
You asked the Plan to pay for the dental service. You say that the same tooth that had been previously replaced 
fell out. 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 June 29, 2023. Therefore, 
we decided that the Plan does not have to pay for adding a tooth to an existing partial denture (D5650) 
provided on July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on September 13, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had to go to a new dentist and the Plan is 
refusing to pay for your cleaning The Plan denied your request. The Plan says your benefit for the requested 
item or service has already been exhausted. Also, the cleaning (D1110) was paid on 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, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on August 17, 2021; therefore, your benefit 
for the requested item or service was exhausted on the date of service of August 17, 2021. Therefore, we 
decided that the Plan does not have to pay for the intraoral complete series of radiographic images (D0210) 
provided on September 13, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on September 01, 2022. 
 
You asked the Plan to pay for ophthalmological services. You say that the services were medically necessary. 
The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ophthalmological 
services provided on September 01, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 28, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided the proper 
documentation and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of the implant body (D6010) for tooth 
#20 provided on August 5, 2023. 
 
You asked the Plan to pay for the dental service. You say that because the dental implant is placed on your 
jawbone it should be medically covered. The Plan denied your request. The Plan says the denial of payment for 
this service is correct, because dental services are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The requested surgical placement of the implant body in dispute meets the Medicare definition of dental, since 
it is a service which involved the care and treatment of teeth or structures directly supporting the teeth. The 
surgical placement of the implant body does not fall under any of Medicare exceptions for coverage of non-
routine dental care. These are dental services that are not covered or paid for by Medicare. Therefore, we 
decided that the Plan does not have to pay for the surgical placement of the implant body (D6010) for tooth #20 
provided on August 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown-porcelain/ceramic (D2740) and core buildup 
(D2950) provided on October 9, 2023. 
 
You asked the Plan to pay for these dental services. You say that this should be covered at least 50%. 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 a crown-
porcelain/ceramic (D2740) and core buildup (D2950) provided on October 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic image (D0220) provided on 
August 28, 2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denial of payment for the 
x-ray because there is no reasoning and interpretation to support 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 the Plan paid for the intraoral radiographic image (D0220) on May 25, 2023; therefore, your benefit for 
the requested item or service was exhausted on the date of service of May 25, 2023. Therefore, we decided that 
the Plan does not have to pay for the intraoral radiographic image (D0220) provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and core buildup (D2950). 
 
You asked the Plan to pre-approve core buildup. 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 pre-approve a 
crown (D2740) and core buildup (D2950).
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 27, 2023. 
 
You asked the Plan to pay for this dental service. 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 service 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 service provided was exhausted on date of service May 8, 2023.  
  
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images or related 
service is covered every three years. You previously received a panoramic radiographic image (D0330) on  
May 8, 2023, less than three years prior, which was paid for by the Plan. The Plans contract states that this is a 
related service to the service at issue. Therefore, you have exhausted the allowable benefit for the service 
provided in this case. Therefore, we decided that the Plan does not have to pay for the intraoral-comprehensive 
series of radiographic images (D0210) provided on July 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on July 4, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on July 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on August 17, 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 $500 annual maximum 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 $500 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay for 
dental services provided on August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a retainer crown (D6750) for tooth #9 and to pay for a 
pontic (D6240) for tooth #10 provided on July 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan authorized the dental work and if 
you knew that they would not cover it you would not have done the work. 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 $209 for dental services on March 9, 2023. On May 15, 2023, the Plan paid $68.64 for 
dental services. On July 17, 2023, the Plan paid $1,722.36 for dental services. For the year of 2023 the Plan 
paid $2,000 ($209 paid + $68.64 paid + $1,722.36 paid) for dental services; therefore, your annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of July 17, 2023. Therefore, we 
decided that the Plan does not have to pay more for a retainer crown (D6750) for tooth #9 and to pay for a 
pontic (D6240) for tooth #10 provided on July 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on August 26, 2023. 
 
You asked the Plan to pay for ambulance services. You say that the services were medically necessary. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for ambulance services 
provided on August 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit. 
 
You asked the Plan to pay for the office visit. You say that you have tried pain pill and they did not work.  You 
say that you tried a chiropractor, and the pain has eased up so that you can sit for longer periods of time. The 
Plan denied your request. The Plan says the only covered chiropractic service is manual manipulation of the 
spine. 
 
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.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the intraoral-periapical additional radiographic image (D0230) provided on August 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the 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 date of service June 27, 2023.  
  
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. You previously 
received this service on June 27, 2023, less than one year prior, which was paid for by the Plan. Therefore, you 
have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does not have to pay 
for the intraoral-periapical first radiographic image (D0220) and the intraoral-periapical additional radiographic 
image (D0230) provided on August 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the anti-reflective coating and the progressive lens provided 
on August 21, 2023. 
 
You asked the Plan to pay for the anti-reflective coating and the progressive lens. You say that you had cataract 
surgery, and you believe that having progressive lenses on your eyeglasses and sunglasses are very valuable to 
your vision. You say you have light sensitivity, and the anti-reflective coating and polarization prevents eye 
strain. The Plan denied your request. The Plan says the services are not covered benefits. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the anti-reflective coating and the progressive lens 
have not been met. Therefore, we decided that the Plan does not have to pay for the anti-reflective coating and 
the progressive lens provided on August 21, 2023.