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

 
We decided that the Plan does not have to pay for the periapical each additional x-ray (D0230 x 4), bitewing x-
rays (D0274) and 2D oral/facial photographic images (D0350 x 4) provided on August 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider should be responsible for payment 
since they are familiar with insurance guidelines for frequency limitations. 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 items or services was exhausted on dates of service February 28, 2023, 
and August 29, 2023. Therefore, we decided that the Plan does not have to pay for the periapical each 
additional x-ray (D0230 x 4), bitewing x-rays (D0274) and 2D oral/facial photographic images (D0350 x 4) 
provided on August 29, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor June 16, 2023. 
 
You asked the Plan to pay for the office visit. You say that you went to the doctors because of a problem with 
your right hip due to you falling in your back yard. You say that your doctor is in network, and you have 
chiropractic benefits with your Plan. 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 provided by a chiropractor June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse payment for dental services provided on March 26, 2023. 
 
You asked the Plan to reimburse payment for the dental services. You say that the services should be covered 
as you disagree with the charges. The Plan denied your request. The Plan says the reimbursement request 
denied correctly as an itemized bill was not received. 
 
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 documentation was not 
received. Therefore, we decided that the Plan does not have to reimburse payment for dental services provided 
on March 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a 
cleaning (D1110) provided by an out-of-network provider on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are wondering why the Plan did not pay for 
the dental services. The Plan denied your request. The Plan says the dental services were received from an out-
of-network provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), bitewings (D0274), and a cleaning (D1110) provided by an out-
of-network provider on August 9, 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 July 12, 
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 rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (99284) 
provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D0220 and D0230) on June 22, 2023. 
 
You asked the Plan to pay for the dental services (D0220 and D0230). You say that you would like to request 
reconsideration for payment. 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 December 2, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services (D0220 and D0230) on June 
22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam CT capture and interpretation (D0364) 
provided on September 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary to proceed with 
your implant. The Plan denied your request. The Plan says this service is not a covered benefit under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the cone 
beam CT capture and interpretation (D0364) provided on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an amalgam (D2150 and D2160) for tooth #14 and #19 
provided on August 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your dentist said you needed a filling, and 
you are getting a denial letter. The Plan denied your request. The Plan says the denial of payment for the resin-
based composites is correct, because white fillings on posterior teeth will be processed as a silver filling; 
therefore, the payment for the amalgams was appropriate. Also, the proper cost share was applied. 
 
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 total allowed amount for the denied resin-based composite (D2392) for tooth #14 was $171 and the total 
allowed amount for the approved amalgam (D2150) for tooth #14 was $121 leaving a difference of $50 ($171 
total - $121 total). The total amount after the $100 deductible was applied was $21 ($121 allowed - $100 
deductible). The total coinsurance amount was $10.50 ($21 total x 50% coinsurance). The total enrollee 
liability was $160.50 ($50 difference + $100 deductible + $10.50 coinsurance). 
 
The total allowed amount for the denied resin-based composite (D2393) for tooth #19 was $208 and the total 
allowed amount for the approved amalgam (D2160) for tooth #19 was $147 leaving a difference of $61 ($208 
total - $147 total). The total coinsurance amount was $73.50 ($147 allowed x 50% coinsurance). The total 
enrollee liability was $134.50 ($61 difference + $73.50 coinsurance). 
 
You have been asked to pay the difference between the approved silver fillings and white fillings along with a 
$100 deductible and the 50% coinsurance. 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 an amalgam 
(D2150 and D2160) for tooth #14 and #19 provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on August 10, 
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 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 March 30, 2023. 
Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140) provided on 
August 10, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the interspinous decompression spacer (Superion 
Vertiflex) procedure. 
 
You asked the Plan to pre-approve the Superion Vertiflex procedure. You say that you recommend this 
procedure due to the failure of conservative treatments. It is a safer alternative to a laminectomy or spinal 
fusion. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered. 
 
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 the Superion Vertiflex procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found that the Superion Vertiflex procedure is considered 
experimental/investigational and is not medically necessary for the treatment of chronic back pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Superion Vertiflex procedure have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the interspinous decompression spacer (Superion Vertiflex) procedure.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extraction (D7210) and limited oral evaluation (D0140) 
provided on August 7, 2023. 
 
You asked the Plan to pay for extraction and limited oral evaluation . You say that this should be covered. The 
Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for extraction 
(D7210) and limited oral evaluation (D0140) provided on August 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OneTouch Ultra test strips. 
 
You asked the Plan to pre-approve the blood glucose test strips. You say that the requested test strips are 
medically necessary to treat the enrollee. The Plan denied your request. The Plan says only the preferred brand 
products listed in the EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for the blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve OneTouch 
Ultra test strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic oral evaluation (D0120), bitewing x-rays 
(D0274), prophylaxis (D1110) and mandibular partial denture (D5214) provided on June 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware your provider was out-of-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the periodic oral evaluation (D0120), bitewing x-rays (D0274), prophylaxis (D1110) and mandibular 
partial denture (D5214) provided on June 8, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from April 27, 2022, to May 
26, 2022. 
 You asked the Plan to pay for home health services. You say that you have billed the services at issue correctly. 
The Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is January 27, 2022. The NOA was not received by the Plan until June 3, 
2022. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from April 27, 2022, to May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pontic (D6240 x4), custom fabricated abutment  includes 
placement (D6057 x4) and abutment supported porcelain/ceramic crown (D6058 x4). 
 
You asked the Plan to pay for these dental services. You say that these should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
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 pontic 
(D6240 x4), custom fabricated abutment  includes placement (D6057 x4) and abutment supported 
porcelain/ceramic crown (D6058 x4).
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 August 22, 2023. 
 
You asked the Plan to pay for the dental service. You say that you changed dentists because the provider kept 
canceling your 2 cleanings which you are entitled to. You also say that you had new x-rays taken with the new 
dentist as the provider never sent your records to the 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 February 10, 2022.  Therefore, we decided that the Plan does not have to pay for the intraoral  comprehensive series of 
radiographic images (D0210) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D2392 and D7210). 
 
You asked the Plan to pre-approve the dental services (D2392 and D7210). You say that you would like to 
request reconsideration of the denied claim and that the services requested are medically necessary. 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. Therefore, 
we decided that the Plan does not have to pre-approve the dental services (D2392 and D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a tooth addition to an existing partial 
denture, extraction, and labial veneer (D2960, D7140, D5650) provided on July 5, 2023. 
 
You asked the Plan to waive the coinsurance for the dental services. You say that the services should be 
covered as you disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied 
correctly based on the services provided. Coverage for the labial veneers 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 labial veneers are not among those 
covered under this benefit.  
 
You have been asked to pay a 50% coinsurance for a tooth addition to an existing partial denture and 
extraction. These services fall 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 coinsurance for a tooth addition to an existing partial denture, extraction, and labial veneer (D2960, D7140, 
D5650) provided on July 5, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on August 4, 
2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. 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 physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. 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 a 
continuous glucose monitor (CGM) provided on August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #4. 
 
You asked the Plan to pre-approve the dental service. You say that the requested dental services are necessary 
because you are in pain, and you cannot eat properly. 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 the Plan paid for the surgical placement of implant body (D6010) for tooth #20 on October 16, 2023, 
and approved the surgical placement of implant body (D6010) for tooth #5 on November 29, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of approval of November 29, 2023. 
Therefore, we decided that the Plan does not have to pre-approve the surgical placement of implant body 
(D6010) for tooth #4.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110), periodic oral evaluation 
(D0120), intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic 
images (D0230 x 2), and the bitewing x-rays-four radiographic images (D0274) provided on September 26, 
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 that you received the dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental 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 
dental cleaning (D1110), periodic oral evaluation (D0120), intraoral-periapical first radiographic image 
(D0220), intraoral-periapical additional radiographic images (D0230 x 2), and the bitewing x-rays-four 
radiographic images (D0274) provided on September 26, 2023.