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

 
We decided that the Plan does not have to pay for surgical placement of implant body (D6010) and sinus 
augmentation via a vertical approach (D7952) provided on May 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that the enrollee needs these services, because the 
enrollee has a limited alveolar ridge height. You also say that the lack of alveolar ridge height means the 
implant cannot be placed without perforating the sinus. 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 annual maximum allotment was exhausted on date of service May 17, 2023. Therefore, we decided 
that the Plan does not have to pay for surgical placement of implant body (D6010) and sinus augmentation via 
a vertical approach (D7952) provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the), intraoral - periapical first radiographic image (D0220), 
intraoral - periapical each additional radiographic image (D0230), and limited oral evaluation - problem 
focused (D0140) provided on April 4, 2023, and April 25, 2023. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the intraoral - periapical first radiographic image, intraoral - periapical each additional radiographic image, and 
limited oral evaluation - problem focused has already been exhausted. Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested intraoral - periapical first radiographic image, intraoral - periapical each 
additional radiographic image, and limited oral evaluation - problem focused was exhausted on date of service 
June 19, 2023. Therefore, we decided that the Plan does not have to pay for the intraoral - periapical first 
radiographic image (D0220), intraoral - periapical each additional radiographic image (D0230), and limited 
oral evaluation - problem focused (D0140) provided on April 4, 2023, and April 25, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the diagnostic casts is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for diagnostic casts 
(D0470) provided on April 25, 2023. 
 
Your complaint about the unprofessional manner with the office staff is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0230) for 
tooth number 8, an intraoral - periapical each additional image (D0230) for tooth number 25, bitewings 
(D0274), periodontal maintenance (D4910), gingival irrigation with a medicinal agent (D4921), topical 
application of fluoride varnish (D1206) and periodic oral examination (D0120) provided on August 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have not been satisfied with a previous 
dentist. You also say that you were sent to this provider by the Plan knowing you were out of benefits. 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 annual maximum allotment was exhausted on date of service March 22, 2023. Therefore, we 
decided that the Plan does not have to pay for intraoral - periapical first radiographic image (D0230) for tooth 
number 8, an intraoral - periapical each additional image (D0230) for tooth number 25, bitewings (D0274), 
periodontal maintenance (D4910), gingival irrigation with a medicinal agent (D4921), topical application of 
fluoride varnish (D1206) and periodic oral examination (D0120) provided on August 24, 2023.  
 
Your complaint about the lack of potential help from the Plan and the potentially poor service received from 
the previous dentist is not a valid appeal for medical coverage. This part of your complaint is a grievance that 
must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 19, 2023. 
 
You asked the Plan to pay for the dental service. You say that you obtained a pre-approval for a second 
opinion, and you would like the claim 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 the Plan paid for a limited oral evaluation (D0140) on March 9, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of March 9, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on August 1, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were informed by the Plan that your 
dental services would be completely covered. 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 periodic oral evaluation (D0120) and 
prophylaxis (D1110) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for computerized corneal topography (92025) provided on July 
26, 2023. 
 
You asked the Plan to pay for computerized corneal topography (92025). You say that this procedure was 
required to evaluate my eye for astigmatism, associated with cataract surgery. You also say this was medically 
necessary and was ordered by the physician. The Plan denied your request. The Plan says this is a non-covered 
service. 
 
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 outpatient physician services for the diagnosis and treatment of diseases and injuries 
of the eye, including treatment for age-related macular degeneration. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan covers outpatient physician services 
for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular 
degeneration. Computerized corneal topography is not covered from this benefit. Based on this information, we 
decided that the Plan's rules for coverage of computerized corneal topography (92025) have not been met. 
Therefore, we decided that the Plan does not have to pay for computerized corneal topography (92025) 
provided on July 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewings - four radiographic images (D0274), periodic 
oral evaluation - established patient (D0120), prophylaxis - adult (D1110), and intraoral - periapical first 
radiographic image (D0220) provided on April 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not made aware that your dental 
provider would not be contracted with your dental plan any longer. 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 bitewings - four radiographic images (D0274), periodic oral evaluation - established patient 
(D0120), prophylaxis - adult (D1110), and intraoral - periapical first radiographic image (D0220) provided on 
April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the porcelain/ceramic crown (D2740) and the 
prefabricated post and core in addition to a crown (D2954) provided on July 10, 2023. 
 
You asked the Plan to pay more for the dental items. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 porcelain/ceramic crown (D2740) and 
the prefabricated post and core in addition to a crown (D2954) provided on July 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter (A4221) and the Xembify injection (J1558) provided on July 12, 2023. 
 You asked the Plan to pay for the supplies for maintenance of non-insulin drug infusion catheter (A4221) and 
the Xembify injection (J1558). The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the supplies for maintenance of non-insulin drug infusion 
catheter (A4221) and the Xembify injection (J1558) provided on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) provided on September 12, 
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 9, 2023.  
  
 
 
 
 
 
Specifically, the Plans contract states that two dental cleanings are covered per year. You previously received 
dental cleanings on January 9, 2023 and May 9, 2023 accordingly, less than one year prior, which were 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 dental cleaning (D1110) provided on September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation with limited field of view-less than one whole jaw (D0364) provided on September 6, 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 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 September 6, 2023.  
  
 
 
 
 
 
Specifically, the Plans contract states that a cone beam CT capture and interpretation with limited field of 
view-less than one whole jaw (D0364) is covered once every 60 floating months. On this day, you received two 
cone beam CT scans, in which one 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 cone beam computed 
tomography (CT) capture and interpretation with limited field of view-less than one whole jaw (D0364) 
provided on September 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays-four radiographic images (D0274) 
provided on August 10, 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 February 9, 2023.  
  
 
 
 
 
 
Specifically, the Plans contract states that one set of bitewing x-rays-four radiographic images (D0274) is 
covered per plan year. You previously received this service on February 9, 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 bitewing x-rays-four radiographic images (D0274) 
provided on August 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment and the acupuncture 
services provided on August 30, 2023, by an out-of-network (OON) provider.  
 
  You asked the Plan to pay for the chiropractic manipulative treatment and the acupuncture services. You say 
that you are a participating provider with traditional Medicare and in the past all Medicare type or Medicare 
Advantage plans have paid whether you have a contract with that particular plan or not. You say that you have 
spoken to several representatives and have filed appeals with having the decision be reversed every time. The 
Plan denied your request. The Plan says the chiropractic manipulative treatment and the acupuncture services 
are available in network. 
 
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 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 the chiropractic manipulative treatment and the 
acupuncture 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 more for the limited oral evaluation (D0140), and intraoral - 
periapical first radiographic image (D0220) provided on July 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that your personal insurance broker informed 
you that the provider was in-network and you should be able to rely on those who have the tools to look up 
providers and trust what they say. You also say that you are seeking coverage for the difference between the 
billed and allowed amounts. 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 limited oral evaluation (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on July 24, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on March 27, 2023. You asked the Plan to pay for the ambulance services. You say that the enrollee was no longer enrolled in 
hospice on the date of service. The Plan denied your request. The Plan says Original Medicare is responsible 
for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on March 11, 2023. The services in question were provided 
before the end of that month. Therefore, we decided that the Plan does not have to pay for the ambulance 
services provided on March 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on 
August 30, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that your first x-ray was with a 
different provider. You also say that you had a dislocated jaw and needed new x-rays, which was unrelated to 
those taken earlier. 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 July 12, 2023. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on August 
30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided on August 3, 2023, to, 
to August 4, 2023. 
 
You asked the Plan to pay for the self-administered drugs. You say that you did not self-take the drugs because 
your physician ordered them for you. The Plan denied your request. The Plan says that self-administered drugs 
do not fall under Medicare Part B coverage. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided on August 3, 2023, to, to August 4, 2023.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment without transport 
services received on February 27, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment without transport services. You say that 
the services were medically necessary. The Plan denied your request. The Plan says without transport there are 
no payable services. 
 
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 February 27, 2023. 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 without 
transport services received on February 27, 2023.