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

 
We decided that the Plan does not have to pre-approve a limited oral evaluation (D0140), an intraoral - 
periapical first radiographic image (D0220), an intraoral - periapical each additional image (D0230), and a cone 
beam computed tomography capture and interpretation (D0364) provided on June 12, 2023. 
 
  You asked the Plan to pre-approve a limited oral evaluation (D0140), an intraoral - periapical first radiographic 
image (D0220), an intraoral - periapical each additional image (D0230), and a cone beam computed 
tomography capture and interpretation (D0364). You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says a cone beam computed tomography capture and interpretation (D0364) 
is not a covered benefit. The Plan also says that the benefit for a limited oral evaluation (D0140), an intraoral - 
periapical first radiographic image (D0220), and an intraoral - periapical each additional image (D0230) has 
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, a cone beam computed tomography 
capture and interpretation (D0364) are not among those covered under this benefit. The record shows that the 
benefit was exhausted on June 8, 2023. Therefore, we decided that the Plan does not have to pre-approve a 
limited oral evaluation (D0140), an intraoral - periapical first radiographic image (D0220), an intraoral - 
periapical each additional image (D0230), and a cone beam computed tomography capture and interpretation 
(D0364) provided on June 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a vitrectomy (67036) provided on May 12, 
2023. 
 
You asked the Plan to waive the copayment for a vitrectomy (67036). You say that the lens the provider put in 
was flipped over and the company should have to pay for it. You also say this was a second operation to 
remove the incorrect lens to put another one in. 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 $370 
copayment for other outpatient procedure and services, including, but not limited to, diagnostic and therapeutic 
endoscopy, and outpatient surgery performed in an outpatient hospital.  
You have been asked to pay a $370 copayment for a vitrectomy (67036). This item/service falls within the 
other outpatient procedure and services, including, but not limited to, diagnostic and therapeutic endoscopy, 
and outpatient surgery performed in an outpatient hospital 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 a vitrectomy (67036) provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a cone beam (D0367) 
provided on May 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services were billed as routine, and it was 
not routine because of your left side of your jaw. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the enrollee does not have supplemental dental coverage. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) 
and a cone beam (D0367) provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) provided on June 15, 2023. 
 
You asked the Plan to pay for the dental service. You say that your coverage includes a crown and 
reimbursement of up to $1,000. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the crown 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 a crown 
(D2740) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medicaments (D9630) provided on March 23, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were never informed about the required 28 
days and you would like the Plan to pay for the dental services. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because 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 Plan's 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 
medicaments (D9630) provided on March 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). You asked the Plan to pre-approve the CGM. You say that you are appealing the denied CGM. The Plan denied 
your request. The Plan says the Medicare criteria was not met. 
 
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. Specifically, the form completed by the enrollees physician indicates 
that the enrollee does not use insulin or have a history of problematic hypoglycemia. 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).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care supplies provided on November 22, 2021. 
 
You asked the Plan to pay for the wound care supplies. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says for an enrollee in a covered inpatient stay, 
Medicare does not make separate payment for medical supplies when the enrollee is in the institution. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 
Records show that the wound care supplies were used in a SNF or hospital. Therefore, we decided that the Plan 
does not have to pay for the wound care supplies provided on November 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture services provided on May 24, 2023, to June 
19, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that that your doctor told you that they have 
had problems with the Health Plan, so you paid out of pocket for your services. The Plan denied your request. 
The Plan says the only covered acupuncture service is for chronic back pain. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, pain not associated with chronic back pain is not 
covered under your Medicare benefit. Therefore, we decided that the Plan does not have to pay for the 
acupuncture services provided on May 24, 2023, to June 19, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 26, 2023. 
 
You asked the Plan to pay for laboratory services. You say that the services were medically necessary 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 laboratory services 
provided on May 26, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided on June 
29, 2023. 
 You asked the Plan to pay for the SNF services. You say that the enrollee was no longer on hospice when the 
services were provided. The Plan denied your request. The Plan says Original Medicare is responsible for 
payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Original Medicare is responsible for payment for services until the first day of the month after the 
hospice election has been revoked or terminated. 
 
The enrollee ended Medicare Hospice benefits on June 21, 2023. The services in question were provided before 
the end of that month. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility 
(SNF) services provided on June 29, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next Test In Vitro Strips. 
 
You asked the Plan to pre-approve Contour Next Test In Vitro Strips. You say that the enrollee would like to 
continue using Contour Next Test In Vitro Strips. The Plan denied your request. The Plan says only the 
preferred brand products listed in the EOC are covered.  
 
The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for Contour Next Test In Vitro Strip. Therefore, we decided that the Plan does not have to pre-approve Contour 
Next Test In Vitro Strips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on March 30, 
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 17, 2023, and 
February 22, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140) provided on March 30, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from May 22, 2023, to May 
23, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you do not understand why the payment 
for the drugs have been denied. 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 May 22, 2023, to May 23, 2023.  
 
Benefits for self-administered drugs may be available under Medicare Part D. Contact the Plan that administers 
Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical procedure for isolation of tooth with rubber 
dam (D3910). 
 
You asked the Plan to pre-approve 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 pre-approve a 
surgical procedure for isolation of tooth with rubber dam (D3910).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for resin-based composite - two surfaces, posterior 
(D2392) provided on July 7, 2023. 
 
You asked the Plan to pay more for the resin-based composite. You say that you had a broken tooth and the 
filling was half out and you needed it to be fixed. The Plan denied your request. The Plan says you are 
responsible for the difference between those allowed amount charges. In addition, you pay 50% coinsurance 
after $100 deductible for Class 2 Basic services. 
 
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 difference between the allowed amounts: $155.54 (D2392 resin-based composite) minus $120.96 (D2150 
amalgam-two surfaces) = $34.58 (your responsibility).  
 
Amount of dental services after Plan deductible: 
$120.96 (allowed amount of D2150 amalgam-two surfaces) minus $100 (your deductible) = $20.96 (allowed 
amount after deductible). 
 
Plan's payment towards Class 2 Basic Services: $20.96 minus 50% = $10.48 (dental plan paid towards the 
service). 
 
Your Total  Responsibility: 
$100 (deductible) + $34.58 (difference between the allowed amounts) + $10.48 (50% your responsibility 
towards Class 2 services) = $145.06 (your total responsibility). 
 
Based on this information, we have determined that this claim has processed correctly. Per your contract with the 
Plan indicates that you are responsible for the difference between the allowed amounts, the deductible and 
coinsurance. The records indicate that these have been applied appropriately. Therefore, we decided that the Plan 
does not have to pay more for resin-based composite - two surfaces, posterior (D2392) provided on July 7, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on February 2, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2023, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the OTC items provided on March 15, 2023. 
 
You asked the Plan to pay for the OTC items. You say that you did not receive any information on the 2023 
Pick Your Perks benefit, and you used the information you had from the 2022 form. The Plan denied your 
request. The Plan says the service is not a covered benefit. 
 
Medicare generally does not cover OTC items. However, the Plan offers an OTC benefit that exceeds Medicare 
coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers an OTC benefit in excess of Medicare coverage, the requested item is not among those 
covered under this benefit. Specifically, the record shows the claim was received on July 17, 2013, which 
exceeds the 120-day limit for reimbursement. Therefore, we decided that the Plan does not have to pay for the 
OTC items provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit and laboratory service provided on May 23, 
2023, by an OON provider.  
 
You asked the Plan to pay for the office visit and laboratory service. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says the service was not 
authorized. 
 Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the office visit and laboratory service provided on 
May 23, 2023, by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified periodontal procedures (D4999) provided on 
April 14, 2023, to April 17, 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 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 Plan's 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 
unspecified periodontal procedures (D4999) provided on April 14, 2023, to April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on May 4, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this is medically necessary. 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 May 17, 2022. Therefore, 
we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided on May 4, 
2023.