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

 
We decided that the Plan does not have to pay for the dental cleaning (D1110) and each periapical x-ray 
(D0230) provided on August 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services are not clearly outlined. You say 
you received a bill from your dentist advising you that the third cleaning is not covered.  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 dental cleanings were exhausted on date of service February 21, 2023, and May 24, 2023. The record shows your benefit for the periapical x-ray was exhausted on August 30, 2023. Therefore, we 
decided that the Plan does not have to pay for the dental cleaning (D1110) and each periapical x-ray (D0230) 
provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral complete 
x-rays (D0210), and adult prophylaxis (D1110) provided from September 14, 2023, to September 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you called in August 2023 and spoke with a 
Plan representative. You also say you should be refunded for the misinformation given to you, since the dentist 
was actually out-of-network. 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 comprehensive oral evaluation (D0150), intraoral complete x-rays (D0210), and adult prophylaxis 
(D1110) provided from September 14, 2023, to September 21, 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 on July 17, 2023. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the only covered 
chiropractic service is manual manipulation of the spine. 
 
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 on July 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on July 7, 2023 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the necessary documents 
for these supplies to be covered. 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 
provided on July 7, 2023
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder test (0013M) provided on September 8, 2023. 
 
You asked the Plan to pay for the Cxbladder test. You say that this testing was medically necessary. The Plan 
denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. The service at issue is non-covered.  Therefore, we decided that the 
Plan does not have to pay for the Cxbladder test (0013M) provided on September 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core in addition to a crown (D2954) 
provided on August 7, 2023. 
 
You asked the Plan to pay for D2954. You say that you believe that this should be covered. The Plan denied 
your request. The Plan says the denied dental service 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, 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 
prefabricated post and core in addition to a crown (D2954) provided on August 7, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 9, 2023. 
 
You asked the Plan to pay for the services. You say that this should be paid for. 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. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150), intraoral complete 
x-rays (D0210) and an adult prophylaxis (D0110) provided on May 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you changed dentists. You also say you asked 
the dentist if they took this Plan and they stated they did. 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 comprehensive oral evaluation (D0150), intraoral complete x-rays (D0210) and an adult prophylaxis 
(D0110) provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Prophylaxis (code D1110) provided on September 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that teeth cleaning is listed as a necessary dental 
service not cosmetic and was provided by an in-network provider. You say that since there is no limit of 
cleanings listed in the Plan documents and you have not reached the maximum benefit amount, the services 
should be covered. 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 service was exhausted on dates of service January 23, 2023 and  May 24, 2024. Therefore, we decided that the Plan does not have to pay for Prophylaxis (code D1110) 
provided on September 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) (A4239) provided on 
August 18, 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 they do not meet the clinical 
requirements to be approved. 
 
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) provided on August 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for destruction of lesion(s) by physical or chemical method 
(D7465) provided on August 1, 2023. 
 
You asked the Plan to pay for destruction of lesion(s) by physical or chemical method. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says destruction of lesion(s) by 
physical or chemical method (D7465) 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 pay for 
destruction of lesion(s) by physical or chemical method (D7465) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the oral hygiene instructions (D1330) and the gingival 
irrigation (D4921) for all 4 quadrants provided on September 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan told you the provider was in-network 
and the provider told you that the entire procedure would be covered. The Plan denied your request. The Plan 
says the denial of payment for these services is correct because the oral hygiene instructions and the gingival 
irrigation are not covered by the Plan. Also, it was verified that you were told the proper benefits and provider 
status prior to the date of service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, 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 oral 
hygiene instructions (D1330) and the gingival irrigation (D4921) for all 4 quadrants provided on September 5, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hearing aids (V5267) provided on February 6, 2023. 
 
You asked the Plan to pay for hearing aids. You say that it took the insurance company eight months to find the 
mistake. You also say that you feel it is the Plan's responsibility for the mistake. The Plan denied your request. 
The Plan says they took a second look at this previously processed claim. The Plan also says that this is the 
adjustment they made on it. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan reimburses 
you up to $2,500 per ear every 24 months towards the cost of hearing aids. 
 
  We looked at the file, and the Plan's rules. The Plan rules say that you are entitled to $2,500 per ear every 24 
months towards the cost of hearing aids. The record shows that the Plan overpaid the cost share by $490. 
Although the Plan made the mistake, your cost share, which you agreed to, is only $2,500 per ear. Based on 
this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Therefore, we 
decided that the Plan does not have to pay for hearing aids (V5267) provided on February 6, 2023.
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 July 12, 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 July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of torus palatinus (D7472) provided on August 16, 
2023. 
 
You asked the Plan to pay for removal of torus palatinus (D7472). You say that you feel this should be taken 
care of by the Plan considering this could have become an oral cavity cancer. The Plan denied your request. 
The Plan says this 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, 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 removal 
of torus palatinus (D7472) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for replace missing or broken teeth - complete denture (D5520) 
provided on July 18, 2023. 
 
You asked the Plan to pay for replace missing or broken teeth - complete denture. You say that you were given 
inaccurate information by the Plan representative about your coverage. You also say that you were told you had 
$1,500 in coverage. The Plan denied your request. The Plan says this 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, the requested items or services are not 
among those covered under this benefit. The record shows that the inquiry made to the Plan was about the 
recement of a denture. However, this appeal is regarding replace missing or broken teeth - complete denture 
(D5520). Therefore, we decided that the Plan does not have to pay for replace missing or broken teeth - 
complete denture (D5520) provided on July 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and the related supply 
allowance provided by an out-of-network provider on July 29, 2023. 
 
You asked the Plan to pay for the CGM and related supply allowance. You say that you have provided all the 
required documents and you 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 a continuous glucose monitor (CGM) and the 
related supply allowance provided by an out-of-network provider on July 29, 2023.
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 September 17, 2023. 
 
You asked the Plan to pay for the core buildup. You say that you were seen by the office while on vacation 
because you were having discomfort due to an abscess that could potentially reach your brain. The Plan denied 
your request. The Plan says procedure code D2950 is not a listed 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 service 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 September 17, 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 by an out-of-network provider on June 30, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have provided all the 
required documents 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 June 30, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the prosthetics provided on August 2, 
2023, and August 3, 2023. 
 
You asked the Plan to waive the coinsurance for the prosthetics. You say that you had a review of your feet and 
the podiatrist recommended the orthotics and braces. You also say that had you know these items would have 
been this expensive you would not have purchased them. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for external prosthetic or orthotic devices and supplies (including wound care supplies), and 
surgical boots when provided during an outpatient visit.  You have been asked to pay a 20% coinsurance for the prosthetics. These items fall within the prosthetic 
devices and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the 
prosthetics provided on August 2, 2023, and August 3, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided by an out-of-network 
provider from June 25, 2023, to July 24, 2023. 
 
You asked the Plan to pay for the home health services. You say that you are appealing the denied claim. The 
Plan denied your request. The Plan says the rendering provider is a non-Medicare participating provider. 
 
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 home health services provided by an 
out-of-network provider from June 25, 2023, to July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pontic (D6240), and a retainer crown (D6750) provided on 
September 11, 2023. 
 
You asked the Plan to pay for D6240 and D6750. You say that this dental work should be covered. The Plan 
denied your request. The Plan says the rendered dental services are not covered 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 a pontic 
(D6240), and a retainer crown (D6750) provided on September 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for diabetic supplies provided on August 3, 2023. 
 
You asked the Plan to pay for diabetic supplies. You say that you have provided all of the appropriate 
information. 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 
provided on August 3, 2023.