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

 
We decided that the Plan does not have to waive the coinsurance for a resin-based composite - one surface, 
anterior (D2330), periodic oral evaluation - established patient (D0120), bitewings - four radiographic images 
(D0274), resin-based composite - one surface, posterior (D2391) provided on December 8, 2022. 
 You asked the Plan to waive the coinsurance for the dental services represented by codes D2330, D0120, 
D0274, and D2391. You say that the Plan did not pay 50% of the total charges. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. Your responsibility would have been less had you used 
an in-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the resin-based composite - one surface, posterior was exhausted on date of service 
December 8, 2022. You received four on this date of service, two were allowed and the Plan paid 50%, and two 
were denied for frequency. 
 
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 50% 
coinsurance for preventive and comprehensive dental services when provided out-of-network.  
 
You have been asked to pay a 50% coinsurance for the dental services represented by codes D2330, D0120, 
D0274. These services fall within the out-of-network preventive and comprehensive dental services benefit 
category. This means that you have been asked to pay the correct amount based on your contract with the Plan. 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The dental 
service represented by D2391 was processed correctly as the Plan paid for the allowed two units at 50% of the 
allowed and the two remaining units are your responsibility. 
 
Therefore, we decided that the Plan does not have to waive the coinsurance for a resin-based composite - one 
surface, anterior (D2330), periodic oral evaluation - established patient (D0120), bitewings - four radiographic 
images (D0274), resin-based composite - one surface, posterior (D2391) provided on December 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia (D9215) provided on January 10, 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 local 
anesthesia (D9215) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, cone beam computed tomography 
(CT) scan, and sales tax (D0140, D0380, D9985) provided on January 9, 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 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. Cone beam CT scans and sales tax are not among those covered 
under your dental benefits. Therefore, we decided that the Plan does not have to pay for a limited oral 
evaluation, cone beam computed tomography (CT) scan, and sales tax (D0140, D0380, D9985) provided on 
January 9, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complex cystometrogram, uroflowmetry, a urinary muscle 
study, and a urine capacity measure ultrasound provided on November 15, 2022, by an OON provider. 
 
You asked the Plan to pay for the diagnostic testing. You say that you are requesting reconsideration of the 
denied claim. The Plan denied your request. The Plan says that these services are not covered when received by 
an out-of-network provider. 
 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the enrollee can use the POS option to receive certain out-of-network services, which does not 
include out-of-network outpatient diagnostic testing. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 a complex cystometrogram, uroflowmetry, a 
urinary muscle study, and a urine capacity measure ultrasound provided on November 15, 2022, by an OON 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 21, 2023, to February 
23, 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 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 dental services provided on February 21, 2023, to February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on January 17, 2023. 
 
You asked the Plan to pay for this item. 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 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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on January 17, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 28, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance service was medically necessary. The Plan denied your request. The Plan says these services are not 
a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 28, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the gym membership (A9270) purchased on 
January 1, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the gym membership purchased is 
not covered under your supplemental benefit policy.  
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case.   
 
The Plans rules for coverage of gym benefits have not been met because the gym membership purchased is not 
covered under your supplemental benefit policy. Specifically, the Plan contract does not provide coverage for a 
tennis club membership. Therefore, we decided that the Plan does not have to issue reimbursement for the gym 
membership (A9270) purchased on January 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery for a portable oxygen concentrator (E1399). 
 
You asked the Plan to pre-approve the battery. You say that the second battery is medically necessary. The 
Plan denied your request. The Plan says duplicate equipment is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and 
necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered 
reasonable and necessary. 
 
The file shows that you have a battery for the oxygen concentrator. The backup battery serves the same purpose 
as the original battery. Therefore, we decided that the Plan does not have to pre-approve a battery for a portable 
oxygen concentrator (E1399).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on July 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that your provider told you the services would 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. This benefit includes the 
requested item or service but is limited to an annual maximum of $3,000. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan paid 
$2,621 on February 18, 2021, $157 on March 30, 2021, $176 on April 22, 2021, and $46 on May 3, 2021, 
which is the annual maximum of $3,000. The record shows your benefit for the requested item or service was 
exhausted on date of service July 21, 2021. Therefore, we decided that the Plan does not have to pay for dental 
services provided on July 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 37229 and 37253 rendered on September 
23, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 37229: 
 
Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed 
 
CPT 37253: 
 
Intravascular ultrasound (noncoronary vessel) during diagnostic evaluation and/or therapeutic intervention, 
including radiological supervision and interpretation; each additional noncoronary vessel (List separately in 
addition to code for primary procedure) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that documentation does not support 
coverage of the codes in question. CPT 37253 codes for the supervision and interpretation of intravascular 
ultrasound (IVUS) of additional arteries following the base code. In this case the details of the IVUS findings 
are inadequate to justify coverage of this code. CPT 37229 codes for tibial/peroneal artery atherectomy with or 
without angioplasty.  In this case there is insufficient documentation of procedural details and of completion 
imaging to establish that meaningful atherectomy and angioplasty was performed on which to overturn the 
health plan determination. While subsequent angiographic description is included in the records provided, it 
appears that these findings were related to a different patient as the name, gender, and birthdate are all 
different.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure codes 37229 and 37253 rendered on September 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) and the 
recement crown (D2920) for tooth #17 provided by an out-of-network provider on April 26, 2022. 
  You asked the Plan to pay more for the dental services. You say that the dentist office never stops billing 
people for services, and you paid out of pocket for the dental services. The Plan denied your request. The Plan 
says you are responsible for any charged amount above the Plans cost-sharing amount when your services are 
received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150) 
and the recement crown (D2920) for tooth #17 provided by an out-of-network provider on April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212) provided on January 18, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told by your insurance company 
that the provider was in-network; therefore, you do not agree that they did not pay for the service. The Plan 
denied your request. The Plan says you are responsible for any charged amount above the Plans cost-sharing 
amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Enrollees must pay $100 
deductible and 50% coinsurance for covered in-network and out-of-network dental services and may be billed 
by the out-of-network provider for any charged amount greater than the payment made by the Plan. 
 
The allowed amount of the covered dental service totals $778.86, resulting in a coinsurance amount of $439.43 
($339.43 50% coinsurance + $100 deductible = $439.43) and a Plan payment amount of $339.43. 
 
You may also be asked to pay the difference between the out-of-network providers charges and the Plans 
payment 
 
This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we 
decided that the Plan does not have to pay more for mandibular partial denture  resin base (including, 
retentive/clasping materials, rests, and teeth) (D5212) provided on January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation services, an unspecified preventative 
procedure, and screening of a member (D4921) provided on January 24, 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 gingival 
irrigation services, an unspecified preventative procedure, and screening of a member (D4921) provided on 
January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the bitewings - four radiographic image 
(D0274), periodic oral evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on 
December 14, 2022. 
 
You asked the Plan to waive the coinsurance for the dental codes represented by D0274, D0120 and D1110. 
You say that you would like to be reimbursed for expenses paid to the dental provider for services. 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 50% 
coinsurance for preventive and diagnostic dental services provided by an out-of-network provider.  
 You have been asked to pay a 50% coinsurance for the dental codes represented by D0274, D0120 and D1110. 
These services fall within the preventive and diagnostic 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 the bitewings - four radiographic image (D0274), periodic oral 
evaluation - established patient (D0120), and prophylaxis - adult (D1110) provided on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2750). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. 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 pre-approve a 
crown (D2750).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a duplex scan of the lower extremities and bilateral 
noninvasive physiologic studies of the lower extremities provided on January 5, 2023, by an OON provider. 
 
You asked the Plan to pay for the ultrasounds. You say that you have never seen this provider before. The Plan 
denied your request. The Plan says that these services are not covered when received by an out-of-network 
provider. 
 
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 Plan contract also says that your POS benefit does not apply 
to out-of-network ultrasounds. 
 The record shows you received these services on January 5, 2023. The requested provider in this case is not a 
network provider with the Plan. The Plan had network providers available who could have provided the 
items/services at issue in this appeal. 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 a duplex scan of the lower extremities and bilateral noninvasive physiologic studies of the 
lower extremities provided on January 5, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and 
intraoral - periapical first radiographic image (D0220) provided on December 27, 2022. 
 
You asked the Plan to pay for dental services. You say that your provider was away so you had to use another 
provider, so you should not have to pay for the services. The Plan denied your request. The Plan says these 
services are not covered under your 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. Limited oral evaluation - 
problem focused (D0140) and intraoral - periapical first radiographic image (D0220) are not covered under the 
Plans dental benefits. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D0140 and D0220 are 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for 
limited oral evaluation - problem focused (D0140) and intraoral - periapical first radiographic image (D0220) 
provided on December 27, 2022.