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

 
We decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images 
(D0330) provided on August 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that this 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 item or service was exhausted on date of service April 28, 2022. 
Therefore, we decided that the Plan does not have to pay for intraoral - comprehensive series of radiographic images (D0330) provided on August 10, 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 a CGM. You say that the enrollee is now on insulin. The Plan denied your 
request. The Plan says while the enrollee is taking medication that are used to treat diabetes, non are considered 
to be injectable insulin. 
 
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. The documentation indicates that the enrollee does not use insulin. 
Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on April 25, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you do not agree 
with the copayment applied. 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 
copayment for outpatient rehabilitation services.  
You have been asked to pay a $20 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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 waive the copayment 
for each physical therapy (PT) visit provided on April 25, 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 CGM. You say that you need this CGM. The Plan denied your request. The 
Plan says the medical criteria for a CGM have not been 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. The documentation 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 CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network nerve burn procedure 
provided on June 30, 2023. 
 
You asked the Plan to waive the deductible for a nerve burn. You say that you usually only page an office 
copay and now its significantly more than that. 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. Your 
contract with the Plan says that there is a $500 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies. You have been asked to pay $347.93 towards this $500 deductible. 
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 This cost sharing is a contractual obligation that had not been met at the time a nerve burn was received on 
June 30, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-network 
nerve burn procedure provided on June 30, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s)  88346, & 88350 billed for date of service 
November 29, 2022. 
 You asked the Plan to pay for procedure code(s)  88346, & 88350. You say that these services were medically 
necessary. The Plan denied your request. The Plan says these codes are included in the facility payment and are 
not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT code(s)  88346, & 88350. This 
means there is both a professional and technical component for the CPT code(s). In this case, an appropriate 
modifier to indicate the professional component has not been billed with CPT code(s)  88346, & 88350. Based 
on this information, we decided that Medicare rules for coverage of procedure code  88346, & 88350 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure code(s)  88346, & 88350 
billed for date of service November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided on March 22, 2023. 
 
You asked the Plan to pay for gingival irrigation. 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 pay for gingival 
irrigation (D4921) provided on March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist office visit provided on January 
24, 2023. 
 
You asked the Plan to waive the copayment for a specialist office visit. You say that this service should be fully 
covered. 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 in-network physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for a specialist office visit. This item/service falls within the in-
network physician/practitioner services, including doctors office visits 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 specialist office visit provided on January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic services provided on January 25, 2023, to March 
6, 2023. 
 
You asked the Plan to pay for chiropractic services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says they cover only manual manipulation of the spine to 
correct subluxation. 
 
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 chiropractic services provided on January 25, 2023, to March 6, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on August 14, 2023. 
 
You asked the Plan to pay for a telehealth visit. You say that this service was 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 a telehealth visit 
provided on August 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy administration provided on April 20, 2023. 
 
You asked the Plan to pay for chemotherapy administration. 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 chemotherapy 
administration provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided on July 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that your first set of dentures did not fit properly. 
You say that the dentist never fixed them. The Plan denied your request. The Plan says your benefit for the 
requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 6, 2022. Therefore, we decided that the Plan does not have to pay for a complete maxillary and mandibular denture (D5110 and 
D5120) provided on July 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biopsy of oral tissue (D7286). 
 
You asked the Plan to pay for the dental service. You say that the claim should have been submitted as medical 
and not dental. The Plan denied your request. The Plan says the denial of payment for this service is correct, 
because the biopsy of oral tissue 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. 
 
The requested biopsy of oral tissue in dispute meets the Medicare definition of dental, since it is a service 
which involved the care and treatment of teeth or structures directly supporting the teeth. The biopsy of oral 
tissue does not fall under any of Medicare exceptions for coverage of non-routine dental care. 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 biopsy of oral 
tissue (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image and endosteal implant 
(D0330, D6010) provided on August 14, 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 dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. Coverage for the endosteal implants 
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. 
 
 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. Coverage for the endosteal implants denied 
correctly as they do not fall within your dental benefits. Therefore, we decided that the Plan does not have to 
pay for a panoramic radiographic image and endosteal implant (D0330, D6010) provided on August 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the bitewings (D0274) and the cleaning (D1110) and to 
pay for the periodic oral evaluation (D0120) provided by an out-of-network provider on June 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the Plan should have covered 50% of the 
claim and it should have been paid the first time around. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider. The proper cost share was applied to the bitewings and cleaning. Also, your 
benefit for the periodic oral evaluation has already been exhausted. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The total amount billed for the bitewings (D0274) was $90 and the total allowed amount was $25 leaving a 
difference of $65 ($90 billed - $25 allowed). The total coinsurance charged was $12.50 ($25 allowed x 50% 
coinsurance). The total amount billed for the cleaning (D1110) was $150 and the total allowed amount was $37 
($150 billed - $37 allowed). The total coinsurance amount was $18.50 ($37 allowed x 50% coinsurance). 
 
You have been asked to pay a 50% coinsurance and 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. The record shows the Plan paid for a periodic oral evaluation (D0120) on June 14, 2023; 
therefore, your benefit for the periodic oral evaluation (D0120) was exhausted on the date of service of June 
14, 2023. Therefore, we decided that the Plan does not have to pay more for the bitewings (D0274) and the 
cleaning (D1110) and to pay for the periodic oral evaluation (D0120) provided by an out-of-network provider 
on June 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on July 
25, 2023. 
 
You asked the Plan to pay for the dental service. You say that they took the image because your tooth was 
chipped, and you assumed it would 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 the Plan paid for a panoramic radiographic image (D0330) on January 6, 2022; therefore, your benefit 
for the requested item or service was exhausted on the date of service of January 6, 2022. Therefore, we 
decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on July 25, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for custom fabricated abutment - includes placement (D6057) 
and abutment supported porcelain/ceramic crown (D6058) provided on August 30, 2022. 
 
You asked the Plan to pay for these dental services. You say that this should be covered. The Plan denied your 
request. The Plan says these are not covered 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. 
 
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 custom 
fabricated abutment - includes placement (D6057) and abutment supported porcelain/ceramic crown (D6058) 
provided on August 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the dental services provided on April 12, 2023. 
 
You asked the Plan to reimburse you for the dental services. You say that you were unaware that the 2023 
submission policy has a deadline of 120 days. You also say that you are requesting a one-time exception of the 
120 day deadline. The Plan denied your request. The Plan says your claim submission was received more than 
120 days after the date of service. 
 Medicare generally does not cover dental services. However, the Plan offers a supplemental benefit that 
exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a Pick You Perks Reimbursement benefit in excess of Medicare coverage, certain rules 
and conditions must be met in order to use this benefit. The Plan requires that all claims must be postmarked 
within 120 days of the purchase/service date. Therefore, we decided that the Plan does not have to reimburse 
you for the dental services provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a gym membership provided on July 10, 2023. 
 
You asked the Plan to reimburse for a gym membership. You say that this is an activation fee for a fitness 
center. The Plan denied your request. The Plan says a gym activation fee is not a covered item and therefore 
not reimbursable. 
 
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 extra benefits 
with the pick your perks program. Gym memberships are excluded from this benefit. 
 
 
  The Plans rules for coverage of gym benefits have not been met because a gym membership is not covered 
with the pick your perk reimbursement program. Therefore, we decided that the Plan does not have to 
reimburse for a gym membership provided on July 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment without transport services 
received on January 9, 2023. 
 
You asked the Plan to pay for ambulance response and treatment without transport services. You say that you 
did not want to be transported to the hospital. The Plan denied your request. The Plan says without transport 
there are no payable services. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on January 9, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment without 
transport services received on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning and periodic oral evaluation (D1110, D0120) 
provided on June 6, 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 January 03, 2023. 
Therefore, we decided that the Plan does not have to pay for a cleaning and periodic oral evaluation (D1110, 
D0120) provided on June 6, 2023,