Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services (S9122) provided on September 15, 
2023. 
 
You asked the Plan to pay for the home health 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 the 
rendering provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for home health services (S9122) provided 
on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the intraoral radiographic 
images (D0220 and D0230), bitewings (D0274), a cleaning (D1110), and the palliative treatment (D9110) 
provided by The Wheelchair Store on March 14, 2023, and March 16, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have used the same dentist before and the 
website shows they are a listed provider. 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. Also, it was 
verified that the provider is 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the intraoral radiographic images (D0220 and D0230), bitewings 
(D0274), a cleaning (D1110), and the palliative treatment (D9110) provided by The Wheelchair Store on 
March 14, 2023, and March 16, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic 
procedure (95999), somatosensory testing (95938), and the electroencephalogram (EEG) (95822) provided on 
May 24, 2022. 
 
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 are not payable as the corrected 
claim was submitted untimely.  
 
The Plan follows Medicare rules. The rules says that a corrected claim must be submitted within one year from 
the date of the initial determination or redetermination for any reason.  
 
  
 
The record shows that a corrected claim for these services was not filed until June 24, 2023. This means that 
more than one calendar year from the date of service had passed before a corrected claim was filed. Therefore, 
we decided that the Plan does not have to pay for the unlisted neurological or neuromuscular diagnostic 
procedure (95999), somatosensory testing (95938), and the electroencephalogram (EEG) (95822) provided on 
May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth requiring removal of bone 
and/or sectioning of tooth (D7210) provided on October 20, 2023. 
 
You asked the Plan to pay for the extraction. You say that you were told the deductible was $104.50 which you 
paid at the time of service. You also say that they are now asking to pay a $100.00 balance. The Plan denied 
your request. The Plan says this procedure is not a 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 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on October 20, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve internal root repair of perforation defects (D3333). 
 
You asked the Plan to pre-approve internal root repair of perforation defects. You say that you are appealing 
with supporting records. The Plan denied your request. The Plan says this service is not covered under your 
benefit 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 
internal root repair of perforation defects (D3333).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239, E2103) 
provided on June 28, 2023, to July 29, 2023. 
 
You asked the Plan to pay for the CGM. You say that the items should be covered as you disagree with the 
denial. The Plan denied your request. The Plan says the items denied correctly as the rendering provider is not 
enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
(A4239, E2103) provided on June 28, 2023, to July 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided on September 
15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware this service was only 
covered once every two years. You also say that you are retired and on a limited income. 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 gingival irrigation for all 4 quadrants was exhausted on date of service May 10, 
2023. Therefore, we decided that the Plan does not have to pay for the gingival irrigation (D4921 x 4) provided 
on September 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic imaging (D0330) provided on October 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 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 August 2, 2023. 
Therefore, we decided that the Plan does not have to pay for panoramic imaging (D0330) provided on October 
9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM). 
 
You asked the Plan to pay for a CGM. You say that a valid proof of delivery was sent. 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. A valid proof of delivery must include the enrollees 
specific address. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor 
(CGM).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided on April 23, 2022. 
 
You asked the Plan to pay for the home health services. You say that the services were provided for wound 
care. You also ask to reprocess the claim because this is not a timely filing claim. The Plan denied your request. 
The Plan says the claim was beyond 12 months of the date of service. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the home health services was not filed until August 11, 2023. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the home health services provided on April 23, 2022.
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 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider didnt discuss doing the x-ray and 
you feel you should not be held responsible for this service. The Plan denied your request. The Plan says your 
benefit for the panoramic radiographic image 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 October 26, 2022. Therefore, we 
decided that the Plan does not have to pay for the panoramic radiographic image (D0330) provided on August 
3, 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 a cleaning 
(D1110) provided by an out-of-network provider on August 16, 2023. 
 You asked the Plan to pay more for the dental services. You say that you are appealing the dental visits. 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. 
 
The total amount billed for the periodic oral evaluation (D0120) was $96 and the total allowed amount was $37 
leaving a difference of $59 ($96 billed - $37 allowed). The total amount billed for the cleaning (D1110) was 
$138 and the total allowed was $59 leaving a difference of $79 ($138 billed - $59 allowed). 
 
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 a 
cleaning (D1110) provided by an out-of-network provider on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), periodontal 
scaling and root planing (D4341), and an adult prophylaxis (D1110) provided on June 9, 2023. 
 
You asked the Plan to pay for a comprehensive oral evaluation, periodontal scaling and root planing, and an 
adult prophylaxis. You say that these procedures were necessary to remove any possibility of oral infection 
before the other procedure could be performed. The Plan denied your request. The Plan says the requested 
service is not covered by Medicare or the health 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 a 
comprehensive oral evaluation (D0150), periodontal scaling and root planing (D4341), and an adult 
prophylaxis (D1110) provided on June 9, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) provided on June 29, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the items denied correctly as the rendering 
provider is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for a continuous glucose monitor (CGM) 
provided on June 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120) provided on August 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are asking for a refund on overpayment. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a complete maxillary denture (D5110) and a complete mandibular denture (D5120) provided on 
August 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided by a chiropractor (99202) on 
September 28, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says this chiropractic service is excluded from coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided by a chiropractor (99202) on September 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a reline of a complete maxillary denture (D5750). 
 
You asked the Plan to pre-approve a reline of a complete maxillary denture. You say that after four months of 
healing, you can see a significant amount of tissue shrink and bone remodeling on the upper arch, requiring a 
hard tissue reline for better function and esthetics of the upper denture. The Plan denied your request. The Plan 
says this claim was 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, the requested items or services are not 
among those covered under this benefit. Specifically, you say that the patient presented to your office on 
August 8, 2023, for delivery of an upper immediate denture. You have not provided any evidence that the 
denture was provided more than 6 months ago. Therefore, we decided that the Plan does not have to pre-
approve a reline of a complete maxillary denture (D5750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental implants, implant abutment, and an implant 
supported bridge (D6078, D6068 and D6999). 
 
You asked the Plan to pre-approve the dental implants. You say that the implants are medically necessary for 
you to have in order for you to digest. You also say that the implants are to be placed in an area where it is 
medically necessary to have those two teeth.  The Plan denied your request. The Plan says dental implants, 
implant abutment, and an implant supported bridge are not included within this coverage. 
 
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 the 
dental implants, implant abutment, and an implant supported bridge (D6078, D6068 and D6999).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an apicoectomy (D3421) and a retrograde filling (D3430) for 
tooth #4 provided on September 27, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing because the procedures were 
medically necessary. The Plan denied your request. The Plan says the denial of payment for these services is 
correct, because the apicoectomy and the retrograde filling 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 an 
apicoectomy (D3421) and a retrograde filling (D3430) for tooth #4 provided on September 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D3431). 
 
You asked the Plan to pre-approve biologic materials to aid in soft and osseous tissue regeneration. You say 
that this should be covered. The Plan denied your request. The Plan says this is not a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
biologic materials to aid in soft and osseous tissue regeneration (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns and core buildup services (D2950, D2740) provided 
on April 21, 2022. 
 
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 crowns 
and core buildup services (D2950, D2740) provided on April 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), mechanical traction 
(97012) and unlisted modality (97039) provided on July 11, 2023. 
 
You asked the Plan to pay for the chiropractic services. You say that the procedures were medically appropriate 
and necessary. The Plan denied your request. The Plan says these chiropractic services are excluded from 
coverage. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the therapeutic exercises (97110), mechanical traction (97012) and unlisted 
modality (97039) provided on July 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye examination provided on 
August 15, 2023. 
 
You asked the Plan to waive the copayment for the medical eye examination. You say that you have been 
going to this practice for 15 years and have never been changed a copayment for a medical eye examination. 
 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 $40 
copayment for non-routine Medicare-covered physician services.  
 
 You have been asked to pay a $40 copayment for the medical eye examination. The medical eye examination 
falls within the vision care 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 the medical 
eye examination provided on August 15, 2023.