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

 
We decided that the Plan does not have to pay more for the comprehensive oral evaluation (D0150), intraoral-
periapical first radiographic image (D0220), intraoral-periapical additional radiographic image (D0230), and 
the bitewing x-rays-four radiographic images (D0274) provided on April 18, 2023. 
 
You asked the Plan to pay more 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 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), 
intraoral-periapical first radiographic image (D0220), intraoral-periapical additional radiographic image 
(D0230), and the bitewing x-rays-four radiographic images (D0274) provided on April 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103). 
 
You asked the Plan to pre-approve the CGM. You say that the items should be covered as the enrollee 
disagrees with the denial. The Plan denied your request. The Plan says the items denied correctly as the 
enrollee does not meet the clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not have diabetes, 
use insulin or have a history of problematic hypoglycemia, had an in-person visit with their treating physician 
to evaluate their diabetes control and to determine whether the criteria for coverage have been met.  Based on 
this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) (E2103).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the specialist office visits, and the back 
brace provided from December 6, 2022, to April 5, 2023. 
 
You asked the Plan to waive the cost share for the specialist office visit and the back brace. You say that you 
disagree with the cost share. 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 $25 
copayment for each Medicare-covered specialist visit. Your contract with the Plan also clearly says that you 
must pay a $20 copayment for each Medicare-covered specialist visit. Your contract with the Plan also clearly 
says that you must pay 20% coinsurance for Medicare-covered items. 
 
You have been asked to pay a $25 copayment for the specialist office visit provided on December 6, 2022. You 
have also been asked to pay a $20 copayment for the specialist office visit provided on April 5, 2023. These 
items/services fall within the physician/practitioner services, including doctors office visits 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.  
 
You have been asked to pay $191.10, which is 20% coinsurance of the allowed amount for the back brace 
provided on February 13, 2023 ($955.49 allowed amount x 20% = $191.10). The item/service falls within the 
physician/practitioner services, including doctors office visits 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 cost share for the specialist office visits, and the back brace provided from December 6, 2022, to 
April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified preventive procedure, by report (D1999) and 
the surgical placement of an implant body: endosteal implant (D6010) provided on April 7, 2023. 
 
You asked the Plan to pay 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 these services 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 pay for the unspecified preventive procedure, by report 
(D1999) and the surgical placement of an implant body: endosteal implant (D6010) provided on April 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cardiology visit provided on February 05, 2023. 
 
You asked the Plan to pay for a cardiology visit. You say that please reconsider for payment, this patient 
needed these services. 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 a cardiology visit 
provided on February 05, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fitting of spectacles (92341) provided on April 18, 2023.  
You asked the Plan to pay for the fitting of spectacles (92341). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says the Plan does not cover this 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 up to $150 toward your purchase of frames (with standard lenses covered in full) or 
contact lenses (fitting and evaluation may be an additional cost). 
 
We looked at the file and the Plan's rules. The Plan rules say that covered services include $150 benefit towards 
the purchase of frames and lenses. The record shows the eyeglass fitting is excluded from this benefit. Based 
on this information, we decided that the Plan's rules for coverage of the fitting of spectacles (92341) have not 
been met. Therefore, we decided that the Plan does not have to pay for the fitting of spectacles (92341) 
provided on April 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each radiation therapy service provided on 
February 24, 2023, to April 21, 2023. 
 
You asked the Plan to waive the copayment for each radiation therapy service. You say that you usually only 
saw a technician, not a physician, and should not have to pay these copayments. 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 $20 
copayment for in-network outpatient therapeutic services provided in a specialists office. 
 
You have been asked to pay a $20 copayment for each radiation therapy service. This item/service falls within the in-network outpatient therapeutic services provided in a specialists office 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 copayment for each radiation therapy service provided on February 24, 2023, to 
April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the new patient eye examination, the office visit, and the 
ophthalmological services to be provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve the vision services. You say that the services are medically necessary. The 
Plan denied your request. The Plan says the requested provider is out-of-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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the vision services. We found no exception that would require the Plan to pre-
approve the vision services. Therefore, we decided that the Plan does not have to pre-approve the new patient 
eye examination, the office visit, and the ophthalmological services to be provided by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and 
comprehensive oral evaluation - new or established patient (D0150) provided on May 9, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image and comprehensive oral evaluation. You say 
that you had to go to a new dentist for a second opinion. You also say that  this was for your first new patient 
visit appointment and x-rays to get your teeth fixed. The Plan denied your request. The Plan says your benefit 
for the requested services 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 services was exhausted on date of service March 30, 2022. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330), and comprehensive 
oral evaluation - new or established patient (D0150) provided on May 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2950, D2740) provided 
on May 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 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 23, 2023. 
Therefore, we decided that the Plan does not have to pay for a crown and core buildup services (D2950, 
D2740) provided on May 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia (D9215) provided on June 14, 2023. 
 
You asked the Plan to pay for the dental service. You say that you could not have had the procedure done 
without the anesthesia. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the local anesthesia is not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the local 
anesthesia (D9215) provided on June 14, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 14, 2023, to April 27, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with the copayments applied to the services provided. 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 $25 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $25 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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 total copayment you owe is $50 for PT services ($25 per visit x 2 visits 
= $50). Therefore, we decided that the Plan does not have to waive the copayment for each physical therapy 
(PT) visit provided on April 14, 2023, to April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bitewing x-ray (D0270) provided on June 13, 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 has not yet 
been exhausted, however, the provider who billed for services provided on February 8, 2023 cannot be the 
same one who bills for your second date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the dental x-rays was exhausted on date of service February 8, 2023. Therefore, we 
decided that the Plan does not have to pay for a bitewing x-ray (D0270) provided on June 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth, and including elevation of mucoperiosteal flap if indicated (D7210) provided on April 12, 
2023. 
 
You asked the Plan to pay for the extraction. You say that you were not informed that this was to be an oral 
surgery and you would not have accepted it if you had known. You also say that you do not want to pay for 
oral surgery. The Plan denied your request. The Plan says this service is not a covered benefit of 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. 
 
 
 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 an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of 
mucoperiosteal flap if indicated (D7210) provided on April 12, 2023.  
 
Your complaint about dental practice and 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for wound care supplies provided on June 01, 
2023. 
 
You asked the Plan to waive the coinsurance for wound care supplies. You say that you do not think you 
should have to pay for the unopened supplies. 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 20% 
coinsurance for durable medical equipment, oxygen/oxygen equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for wound care supplies. This item/service falls within the durable medical equipment, oxygen/oxygen equipment and related supplies 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 total you owe is $1061.58 
($5307.89 allowed amount x 20% = $1061.58 rounded up). Therefore, we decided that the Plan does not have 
to waive the coinsurance for wound care supplies provided on June 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) for 
tooth #5, #6, #20, #21, #22, #27, #28, and #29, and the medicaments (D9630) provided on June 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the service was for a cleaning, and you did not 
receive a bill only a denial letter. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the localized delivery of antimicrobial agents and the medicaments are not covered 
by the 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 
localized delivery of antimicrobial agents (D4381) for tooth #5, #6, #20, #21, #22, #27, #28, and #29, and the 
medicaments (D9630) provided on June 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) and the 
mechanical traction therapy (97012) rendered by the out-of-network (OON) provider on March 15, 2023.  
 
You asked the Plan to pay 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 were rendered by an out-of-
network provider, without prior authorization. Additionally, mechanical traction therapy is not a covered 
benefit.  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Additionally, mechanical traction 
therapy is not a covered benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic 
manipulative treatment (98940) and the mechanical traction therapy (97012) rendered by the out-of-network 
(OON) provider on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified maxillofacial prosthesis (D5999) provided on 
October 25, 2022. 
 
You asked the Plan to pay for the dental service. You say that you thought the dentist would bill the Plan and 
they gave you a bill and said the Plan would not cover the dental services. The Plan denied your request. The 
Plan says the denial of payment for this service is correct, because the unspecified maxillofacial prosthesis is 
not covered by the 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
unspecified maxillofacial prosthesis (D5999) provided on October 25, 2022.