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

 
We decided that the Plan does not have to pay for a complete series of photos (D0210), and an adjunctive pre-
diagnostic test (D0431) provided on August 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you needed this dental work. The Plan denied 
your request. The Plan says these services have been processed correctly. 
 
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 D0210 was exhausted on date of service September 22, 2021. D0431 is not a covered 
dental benefit. Therefore, we decided that the Plan does not have to pay for a complete series of photos 
(D0210), and an adjunctive pre-diagnostic test (D0431) provided on August 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the portable oxygen contents and the portable oxygen 
concentrator on August 16, 2023, to September 14, 2023. 
 
You asked the Plan to pay for the portable oxygen contents and the portable oxygen concentrator. You say that 
your doctor ordered oxygen because of hypoxia and a special mattress to prevent bed sores. The Plan denied 
your request. The Plan says the portable oxygen contents and the portable oxygen concentrator is only covered 
when rented. 
 
The Plan follows Medicare rules. Medicare rules state that purchased oxygen equipment is statutorily non-
covered. 
 
In this case, the oxygen equipment at issue was purchased and not rented. Neither Medicare nor the Plan covers 
purchased oxygen equipment. Therefore, we decided that the Plan does not have to pay for the portable oxygen 
contents and the portable oxygen concentrator on August 16, 2023, to September 14, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on 
September 12, 2023. 
 
You asked the Plan to pay for the ED services. You say that you are requesting the claim be reviewed and 
reprocessed for payment. The Plan denied your request. The Plan says Medicare payment cannot be made to 
this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
 
  We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the emergency 
department (ED) services provided on September 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99135 billed for date of service August 17, 
2023. 
 
You asked the Plan to pay for procedure code 99135. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99135 is considered bundled and not separately payable.  
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99135 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99135 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99135 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99135 billed for date of service August 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0274) and topical application of fluoride varnish 
(D1206) provided on September 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the EOC states under preventive services that 
fluoride treatment and dental x-rays are covered every six months. The Plan denied your request. The Plan says 
your benefit for bitewings (D0274) has already been exhausted. Topical application of fluoride varnish 
(D1206) 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, certain limitations apply. The record 
shows your benefit for bitewings (D0274) was exhausted on date of service March 16, 2023. Topical 
application of fluoride varnish (D1206) is excluded from this benefit. Therefore, we decided that the Plan does 
not have to pay for bitewings (D0274) and topical application of fluoride varnish (D1206) provided on 
September 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the maxillary partial denture (D5211) provided on September 
8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called to confirm with the Plan if this was a 
covered benefit and the representative informed you that it was, and no additional coverage was needed. 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 
maxillary partial denture (D5211) provided on September 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided on August 10, 2023. 
 
You asked the Plan to pay for the supply allowance for a continuous glucose monitor. You say that you have 
submitted proof of delivery along with other supporting documentation, but the claim keeps denying for 
missing this information. The Plan denied your request. The Plan says the provider is not a plan contract 
provider and is not enrolled in Medicare as a durable medical equipment supplier. 
 
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 the supply allowance for a continuous 
glucose monitor (CGM) provided on August 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 
25, 2023. 
 
You asked the Plan to pay for the dental service. You say that the denial did not match the procedure. You say 
you have not had a crown dislodged in years. 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 you received two exams on May 16, 2023, and May 26, 2013, which exhausted the benefit. Therefore, 
we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on September 
25, 2023.
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 8, 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 8, 2023.  
  
 
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images or related 
service is covered every three years. You previously received a panoramic radiographic image (D0330) on 
February 8, 2023, less than three years prior, which was paid for by the Plan. The Plans contract states that this 
is a related service to the service at issue. Therefore, you have exhausted the allowable benefit for the service 
provided in this case. Therefore, we decided that the Plan does not have to pay for the intraoral-comprehensive 
series of radiographic images (D0210) provided on August 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on June 19, 2023. 
 
You asked the Plan to pay for the dental service. You say that the facility did not pay attention to the codes 
which resulted in an over-charge of $70.35. 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 April 3, 2023. The record 
shows the Plan paid for code D0210. Therefore, we decided that the Plan does not have to pay for the 
panoramic x-ray (D0330) provided on June 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for mandibular partial denture (D5226) provided on June 13, 
2023.  
 
You asked the Plan to pay for mandibular partial denture (D5226). You say that you were not aware that your 
dental services would not be covered under your present insurance Plan. You also say it is your desire to be 
reimbursed for all or some of the fees that you were required to pay. The Plan denied your request. The Plan 
says this claim was denied because the provider has opted out of Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
 
  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
mandibular partial denture (D5226) provided on June 13, 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 with limited 
field of view  less than one whole jaw (D0364) provided on October 30, 2023. 
 
You asked the Plan to pay for the cone beam CT capture. You say that this service was required in order to 
determine the appropriate treatment. 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 with limited field of view  less than one whole jaw (D0364) provided on 
October 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
image (D0220), and the bitewings (D0270) on September 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were concerned that you had a cavity, and 
you only had an x-ray done. The Plan denied your request. The Plan says your benefit for the bitewings has 
already been exhausted. Also, the limited oral evaluation and the intraoral radiographic image 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, certain limitations apply. The record 
shows the Plan paid for the bitewings (D0270) on April 3, 2023; therefore, your benefit for the bitewings was 
exhausted on the date of service of April 3, 2023. The limited oral evaluation and the intraoral radiographic 
image are not covered under the Plans dental benefit. Therefore, we decided that the Plan does not have to pay 
for a limited oral evaluation (D0140), the intraoral radiographic image (D0220), and the bitewings (D0270) on 
September 18, 2023.  
 
Your complaint about what services were done and what the provide is billing 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 panoramic radiographic image (D0330) and 2 dimensional 
(2D) oral/facial x-ray (D0350) provided on August 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that when you got to the dentist, they told you that in 
order to proceed with the dental cleaning they had to do some x-rays of your entire mouth. You also say you 
told them no, since the appointment was only for dental cleaning. The Plan denied your request. The Plan says 
your benefit for panoramic radiographic image (D0330) has already been exhausted. The Plan also says that 
two dimensional (2D) oral/facial x-rays (D0350) are 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, certain limitations apply. The record 
shows your benefit for panoramic radiographic image (D0330) was exhausted on date of service August 16, 
2023. Two dimensional (2D) oral/facial x-ray (D0350) are excluded from this benefit. Therefore, we decided 
that the Plan does not have to pay for panoramic radiographic image (D0330) and 2 dimensional (2D) 
oral/facial x-ray (D0350) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic oral examination (D0120), bitewings (D0274) and 
periodontal maintenance (D4910) provided on June 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware of exhausted 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 allowance for the requested item or service was exhausted on date of service 
March 9, 2023. Therefore, we decided that the Plan does not have to pay for periodic oral examination 
(D0120), bitewings (D0274) and periodontal maintenance (D4910) provided on June 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the necessary 
documents. 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 proof of delivery. The proof of delivery provided does not have the 
enrollees signature. 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 diabetic supplies.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on August 3, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documentation and would like the claim processed. 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 proof of delivery. Specifically, there is no signed receipt of the delivery. 
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 the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on August 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you were told that orthotics would be covered at 80% 
and you were never told that you needed a prior authorization. The Plan denied your request. The Plan says this 
item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 31, 2023. 
 
You asked the Plan to pay for the dental service. You say that individual x-rays were taken because it feels 
broken when you chew. You say the x-rays were taken because you need a cap for the tooth. 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 June 21, 2023. Therefore, 
we decided that the Plan does not have to pay for the panoramic x-ray (D0330) provided on August 31, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on September 11, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says when you get the Part D vaccination at your doctor's 
office, you will pay for the entire cost of the vaccine itself and the cost for the provider to give it to you. You 
can then ask the Plan to pay their share of the cost and you will be reimbursed the amount you paid less your 
normal coinsurance or copayment for the vaccine. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on 
September 11, 2023.  
 Benefits for immunization services 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral - periapical x-ray and bitewings provided 
on September 12, 2023. We also decided that the Plan does not have to pay for the comprehensive oral 
evaluation - new or established patient (D0150) provided on September 12, 2023. 
 
 
 You asked the Plan to pay more for the intraoral - periapical first radiographic image (D0220), and bitewings - 
four radiographic images (D0274) provided on September 12, 2023. You also asked the Plan to pay for the 
comprehensive oral evaluation - new or established patient (D0150) provided on September 12, 2023. You say 
that your visit in March was coded as D0150 by your previous dentist. You also say that the new dentist used 
the same code and you have no control over your first dentist deciding to retire. 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. The Plan also says your benefit for the comprehensive 
oral evaluation 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. 
 
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 intraoral - periapical x-ray and bitewings 
provided on September 12, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the comprehensive oral evaluation was exhausted on date of service March 8, 2023. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) provided on September 12, 2023.