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

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on September 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 February 06, 2023. 
Therefore, we decided that the Plan does not have to pay for bitewing x-rays (D0274) provided on September 
20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on August 30, 2023, by an out-
of-network (OON) provider.  
 
  You asked the Plan to pay for the vision services. You say that you were unaware that the treating provider is 
OON. You also say that if you had received a list showing authorized providers, you would have visited a 
doctor that was authorized by the Plan. The Plan denied your request. The Plan says because the provider is 
OON with your plan and because there is no coverage when services are rendered by a non-par provider, the 
Plan will maintain its initial determination to not pay for the submitted claim. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the vision services provided on August 30, 2023, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 19, 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 $2,000 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 $2,000 annual maximum was exhausted. Therefore, we decided that the Plan does not have to pay 
for dental services provided on July 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the intraoral-periapical first radiographic 
image (D0220), intraoral-periapical additional radiographic images (D0230 x2), and the adjunctive pre-
diagnostic test for mucosal abnormalities (D0431) provided on September 6, 2023. 
 
You asked the Plan to issue reimbursement for these services. You say that you are requesting a 
reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services 
provided are not covered under the supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the services provided are not among 
those covered under this benefit.   
Therefore, we decided that the Plan does not have to issue reimbursement for the intraoral-periapical first 
radiographic image (D0220), intraoral-periapical additional radiographic images (D0230 x2), and the 
adjunctive pre-diagnostic test for mucosal abnormalities (D0431) provided on September 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ophthalmological services provided on October 04, 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 October 04, 2022.
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 August 23, 2023. 
 
You asked the Plan to pay for adding a tooth to an existing partial denture (D5650). You say that you have to 
have a tooth added to your existing partial denture in order to eat and chew. The Plan denied your request. The 
Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, adding a tooth to an existing partial 
denture (D5650) is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for adding a tooth to an existing partial denture (D5650) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bone replacement graft (D7953) and removal of residual 
tooth roots (D7250 x4) provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the removal of residual tooth roots has already been exhausted. A bone 
replacement graft 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, certain limitations apply. The record 
shows your benefit for the removal of residual tooth roots was exhausted on date of service September 5, 2023. Therefore, we decided that the Plan does not have to pay for bone replacement graft (D7953) and removal of 
residual tooth roots (D7250 x4) provided on September 5, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial psychiatric collaborative care management (99492) 
provided on August 11, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the initial psychiatric collaborative care management. You say that the patient is 
in a nursing facility and should not have needed an authorization. The Plan denied your request. The Plan says 
the treating provider is not a network provider with the Plan, and the services were not referred by a network 
provider or rendered in a participating facility. The Plan also says that these services are not urgent or 
emergent, nor were they approved in advance. 
 
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 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the initial psychiatric collaborative care 
management (99492) provided on August 11, 2023, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete upper denture (D5110) and complete lower 
denture (D5120) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental items. You say that dental health insurance policies include coverage 
for services rendered by denturists. The Plan denied your request. The Plan says dental services performed by a 
provider that is not a dentist or dental hygienist are not covered. 
 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 and the services at issues in this case 
are listed as covered, payment cannot be made for services performed by someone other than a dentist. The 
record shows that you are a denturist. Therefore, we decided that the Plan does not have to pay for the complete 
upper denture (D5110) and complete lower denture (D5120) provided on August 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay in full for the hearing aids (V5253) purchased on August 15, 
2023, from an out-of-network (OON) provider. 
 
You asked the Plan to pay in full for the hearing aids. You say that the Plan should have reimbursed $1,000 for 
the hearing aids. 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 hearing aids purchased from an OON provider.  
 
 
 You have been asked to pay 25% coinsurance for the hearing aids. This item/service falls within the hearing 
aids 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 in full for the hearing aids (V5253) purchased on 
August 15, 2023, from an out-of-network (OON) provider.
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 each additional radiographic image (D0230) provided on September 6, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider felt as though both x-rays were 
completely medically necessary, as he thought he saw a cavity forming under a tooth crown. The Plan denied 
your request. The Plan says your benefit for the intraoral x-rays 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 January 25, 2023.  Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first radiographic image 
(D0220), and each additional radiographic image (D0230) provided on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3030).  
 You asked the Plan to pre-approve foot orthotics. You say that you are taking the maximum amount of daily 
use to control the intense pain and your only other option is surgery. 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 the requested foot inserts (L3030) are not a covered inserts for a person with diabetes, and 
you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of the requested foot inserts. Therefore, we decided that the Plan does not have to pre-
approve foot orthotics (L3030).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a flexible partial lower denture (D5226). 
 
You asked the Plan to pre-approve the dental item. You say that the base of your current partial denture is very 
weak. You say that you have difficulty eating because the piece comes out. You also say that you need a 
replacement piece, so the bridge is permanent. 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 service was exhausted on date of service May 19, 2022. Additionally, the 
Evidence of Coverage clearly states that adjustments, replacements, and repairs are not covered for flexible 
partial dentures. Therefore, we decided that the Plan does not have to pre-approve a flexible partial lower 
denture (D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in the presence of generalized moderate or severe 
gingival inflammation-full mouth, after oral evaluation (D4346) provided on August 28, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the service provided is not among 
those covered under this benefit.  
  
 
Therefore, we decided that the Plan does not have to pay for the scaling in the presence of generalized 
moderate or severe gingival inflammation-full mouth, after oral evaluation (D4346) provided on August 28, 
2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 3, 2023. 
 
You asked the Plan to pay for the ED services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says Medicare payment cannot be made to this type of 
provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 3, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99284) provided on February 
24, 2022. 
 
You asked the Plan to pay for the ER visit. 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 the claim 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 ER visit was not filed until August 11, 2023. 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 pay for an emergency room (ER) visit (99284) provided on February 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve an MI Tumor Seek Hybrid test. 
 
You asked the Plan to pre-approve an MI Tumor Seek Hybrid test. You say that the services are necessary. The 
Plan denied your request. The Plan says that based on the documentation provided, coverage criteria has not 
been met. 
 
The Plan follows Medicare rules. Medicare rules say that Next Generation Sequencing (NGS) as a diagnostic 
laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory 
Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all 
requirements are met. 
 
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 an MI Tumor Seek Hybrid test. Our 
reviewer says that the services are medically necessary. Our physician reviewer found the criteria have been 
met for the NGS (MI Tumor Seek Hybrid by the Caris Life Sciences). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MI Tumor Seek Hybrid test have been met. Therefore, we decided that the 
Plan has to pre-approve an MI Tumor Seek Hybrid test.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D7210) on September 1, 2023. 
 
You asked the Plan to pay for the dental service (D7210). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
service (D7210) on September 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the progressive lens provided on August 25, 2023. 
 
You asked the Plan to pay for the progressive lens. You say that the physicians were too far away or not taking 
any new patients. You say your optometrist's visit and glasses should be reimbursed. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
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 received by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the progressive lens have not been met. Therefore, 
we decided that the Plan does not have to pay for the progressive lens provided on August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a pontic and retainer crown (D6245, D6740) provided 
on August 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 9, 2023. 
Therefore, we decided that the Plan does not have to pay more for a pontic and retainer crown (D6245, D6740) 
provided on August 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and the resin-based composite-three surfaces, posterior (D2393) provided on 
August 14, 2023. 
 
You asked the Plan to pay for the dental item/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 dental item/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 dental item/service provided was exhausted on date of service July 13, 2023.   
Specifically, the Plans contract states that the annual maximum dental benefit is $2,000. The Plan issued 
payments in the total amount of $2,000 ($848 + $368 + $784) for dental services provided in the 2023 calendar 
year. Therefore, you have exhausted the allowable benefit for the dental item/service provided in this case. 
Therefore, we decided that the Plan does not have to pay for the extraction, of an erupted tooth or exposed root 
(elevation and/or forceps removal) (D7140) and the resin-based composite-three surfaces, posterior (D2393) 
provided on August 14, 2023.