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

 
We decided that the Plan does not have to pre-approve an upper interim complete denture (D5810), a lower 
interim complete denture (D5811), an upper partial denture (D5213), and a lower partial denture (D5214). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested dental items 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 requested items are not among 
those covered under this benefit.  
  
 
 
 
Therefore, we decided that the Plan does not have to pre-approve an upper interim complete denture (D5810), a 
lower interim complete denture (D5811), an upper partial denture (D5213), and a lower partial denture 
(D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the prophylaxis (D1110) provided on February 28, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that your cleaning is covered and should be 
completely free. 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% 
coinsurance for out-of-network preventive dental services. Additionally, enrollees may be billed by the out-of-
network provider for any charged amount greater than the payment made by the Plan. 
 
You have been asked to pay $42.56 for out-of-network preventive dental services. This item/service falls 
within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to pay more for the prophylaxis 
(D1110) provided on February 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code 99070 that 
were issued on December 1, 2022. 
 
You asked the Plan to pay for the compression stockings. You say that you were told to resubmit the claim for 
the stockings after the procedures. The Plan denied your request. The Plan says the code billed does not 
describe the supply being billed; therefore, the denial of payment for the compression stockings is correct. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code 9900 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code 99070 that were issued on December 1, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on March 28, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the replace of a broken tooth (D5640) for tooth #24 provided 
by on March 28, 2023. 
 
You asked the Plan to pay for the dental service. You say that your previous coverage allowed for the dental 
service, and you were never notified of any changes to your coverage. The Plan denied your request. The Plan 
says the denial of payment for this service is correct, because the replace of a broken tooth is not covered by 
the Plan. Also, it was confirmed that the Annual Notice of Change (ANOC) was delivered to you on September 
27, 2022, showing the breakdown of benefits that were available to you. 
 
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 
replace of a broken tooth (D5640) for tooth #24 provided by on March 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of an upper 
extremity joint. 
 
You asked the Plan to pre-approve the MRI. You say that you have already been through surgery and have 
tried therapy and medications. The Plan denied your request. The Plan says the criteria for coverage have not 
been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found there is no documentation of any abnormal 
findings on physical exam. There is no documentation of any response to conservative therapy 
(medication/physical therapy). There is no clinical rationale for the requested MRI. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of an upper extremity joint.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 You asked the Plan to pre-approve the drug. You say that the enrollee wants to take this specific medication.  
The Plan denied your request. The Plan says the step therapy requirements have not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the drug. Our reviewer says that Prolia 
is not medically necessary. Our physician reviewer found that the enrollee has not tried and failed the Plan's 
required drug bisphosphonate. Also, there is no indication that the Plan's required drug would like be less 
effective or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Prolia.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950) 
provided on February 8, 2023. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says this item is 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 item provided is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildup, 
including any pins when required (D2950) provided on February 8, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the leg joint. 
 
You asked the Plan to pre-approve the MRI. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the is no plain imaging studies or failure of provider directed treatment in 
the records.  
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have a swollen left ankle. Achilles 
tendinitis also was considered possible. There are no plain x-rays. You declined physical therapy services. The 
medical necessity of the requested MRI left ankle has not been established in the records provided.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the leg joint.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from February 28, 2023, to 
March 3, 2023. 
 
You asked the Plan to pay for the medication. You say that you were told your bill would only be $120. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  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 self-administered drugs provided 
from February 28, 2023, to March 3, 2023.  
 
Benefits for the medication 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 for the intraoral comprehensive series radiographic images 
(D0210) and the periodontal scaling and root planing (D4342) provided on April 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied services because 
they were needed so your doctor can take the correct path for your health. The Plan denied your request. The 
Plan says the denial of payment for these services is correct, because the intraoral comprehensive series 
radiographic images and the periodontal scaling and root planing 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 
intraoral comprehensive series radiographic images (D0210) and the periodontal scaling and root planing 
(D4342) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120) and a cleaning (D1110) 
provided on March 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was your understanding that the dental 
services are a covered benefit with no cost to you. The Plan denied your request. The Plan says your dental 
maximum benefit for the year 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 $53 for dental services on January 19, 2023. On January 24, 2023, the Plan paid $1,947 for 
dental services. For the year of 2023 the Plan paid $2,000 ($53 paid + $1,947 paid) for dental services; 
therefore, your annual dental maximum benefit for the year of 2023 was exhausted on the date of service of 
January 24, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation 
(D0120) and a cleaning (D1110) provided on March 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional transportation mileage. 
 
  You asked the Plan to pre-approve additional transportation mileage. You say that you need breast 
reconstruction, and there are no providers that perform his procedure within a 50-mile radius from you. You 
also say that you understand this exceeds the 50-mile limit, but you are unable to drive yourself due to vision 
impairment, and there are no community or volunteer resources in your area that can accommodate a trip that 
far. The Plan denied your request. The Plan says you are requesting an additional 26 miles for a total of 76 
miles. The Plan also says that your benefit only allows 50 miles, and this request exceeds your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers routine transportation when each one-way trip does not exceed 50 miles of driving 
distance. 
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plans rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional transportation mileage.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse the sales tax for eyewear provided on March 31, 2023.  
You asked the Plan to reimburse the sales tax for eyewear. You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says you have already received the maximum allowance for 
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 $250 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan reimburses up to $250 every year for 
non-Medicare covered prescription eyewear. The Plan contract also says that the enrollee is responsible for any 
amount above the eyewear coverage limit. The record shows this benefit has been exhausted with this service. 
Based on this information, we decided that the Plan's rules for coverage of sales tax for eyewear have not been 
met. Therefore, we decided that the Plan does not have to reimburse the sales tax for eyewear provided on 
March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), periodic oral evaluation - 
established patient (D0120), and bitewings - four radiographic images (D0274) provided on March 6, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D1110, D0120 and D0274. You say that 
you switched programs but nowhere did you see that the actual dental coverage was going to change. You also 
say that you did not know that there was a difference between the plans and now these services are not covered. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a prophylaxis - adult (D1110), periodic oral evaluation - established patient (D0120), and bitewings - 
four radiographic images (D0274) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a gym membership (S9970) provided on January 1, 2022. 
 
You asked the Plan to pay for a gym membership (S9970). You say that you timely sent the copy of paid 
receipt for the gym twice. You also say you are waiting for your check. The Plan denied your request. The Plan 
says based on a review of the information received, proof of payment is not legible and does not have dates 
showing when paid. The Plan also says that the reimbursement has processed correctly. 
 
The rules say that Medicare does not cover gym benefits. However, the Plan offers a benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers $150 per 
calendar year towards your cost for a membership in a qualified health club or fitness facility during the 
calendar year. 
 
 
  The Plans rules for coverage of gym benefits have not been met because The Plan rules say that they 
reimburse you up to $150 per calendar year towards your cost for a membership in a qualified health club or 
fitness facility during the calendar year. Therefore, we decided that the Plan does not have to pay for a gym 
membership (S9970) provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), a 
cleaning (D1110), and a resin-based composite (D2391) for tooth #4 provided by an out-of-network provider 
on March 9, 2023, and April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services due 
to them not being paid and you need to go back to the same dentist for a crown. 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 periodic oral evaluation (D0120), bitewings (D0274), a cleaning (D1110), and a resin-based 
composite (D2391) for tooth #4 provided by an out-of-network provider on March 9, 2023, and April 5, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from December 1, 
2022, to December 12, 2022. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you were not notified the enrollee 
would be responsible for a copayment. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20 and a $188 copayment per day for days 1 to 20 for SNF care.  
 
 
  The enrollee has been asked to pay $940 copayment for a SNF stay ($188 per day x 5 days = $940). This 
item/service falls within the SNF care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SNF stay provided from December 1, 2022, to December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - resin-based composite (indirect) (D2710) and 
unspecified preventive procedure, by report (D1999) x2 provided on March 27, 2023, and April 4, 2023. 
 
You asked the Plan to pay for dental services. You say that you do not agree with the denial of the services you 
received. The Plan denied your request. The Plan says these services are not covered under your Plan. 
  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Crown - resin-based 
composite (indirect) (D2710) and unspecified preventive procedure, by report (D1999) are not covered under 
the Plans dental benefits. 
 
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 crown - 
resin-based composite (indirect) (D2710) and unspecified preventive procedure, by report (D1999) x2 provided 
on March 27, 2023, and April 4, 2023.