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

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on December 16, 2022. 
 
You asked the Plan to pay for an extraction. You say that this extraction is an emergency. The Plan denied your 
request. The Plan says D7210 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 an 
extraction (D7210) provided on December 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
September 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe the Plan should pay for this. 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 dental services provided by an out-of-network provider on September 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) on January 19, 
2023, to February 1, 2023. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that this should be covered 
because of your health conditions. The Plan denied your request. The Plan says the rendered dental benefit 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 
periodontal scaling and root planing (D4341) on January 19, 2023, to February 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. 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 February 12, 2020. 
Therefore, we decided that the Plan does not have to pay for the dental services on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown- porcelain fused to high noble metal (D2750) and core 
buildup (D2950) provided on November 16, 2022. 
 
You asked the Plan to pay for a crown and core buildup. 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 crown- 
porcelain fused to high noble metal (D2750) and core buildup (D2950) provided on November 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee cannot handle another fall. The Plan 
denied your request. The Plan says that the admission to an IRF is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not have complex nursing or rehabilitation needs. While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is 
not a reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on December 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 the dental 
services on December 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve seven home health physical therapy visits. 
 You asked the Plan to pre-approve home health services. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that you do not 
have documented, ongoing, home health physical therapy needs. You are functioning at a level appropriate for 
a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve seven home health physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an endosteal implant (D6010), nitrous oxide inhalation 
(D9230) provided on January 11, 2023. 
 
You asked the Plan to pay for D6010 and D9230. You say that an implant replacement was selected to avoid 
aggressive treatment. 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 an 
endosteal implant (D6010), nitrous oxide inhalation (D9230) provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite provided on January 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 resin-based composite provided on January 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that they never put any medical equipment in your 
mouth. 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 24, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on 
January 9, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee exceeds the criteria for a 
medically appropriate long term acute care hospital admission. The Plan denied your request. The Plan says 
that the admission to a LTACH is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee does not require services at the LTACH that are not available at the 
acute care hospital where they are currently receiving care. All medically necessary care is being provided in 
the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient basis. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0210) and the 
extractions (D7140) for tooth #3 and #24 and to pay for the limited oral evaluation (D0140) provided by an 
out-of-network provider on November 17, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you read your benefits and the dental 
services should be covered at 100%. 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. Also, the proper cost share was applied. The denial of payment for the limited oral evaluation is 
correct because it 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. 
 
You have been asked to pay for the coinsurance amounts and the difference between the out-of-network 
providers charges and the Plans payment. The total billed amount for the intraoral radiographic image was 
$180 and the total allowed amount was $81 leaving the difference of $99 ($180 billed - $81 allowed). The total 
coinsurance amount for the intraoral radiographic image was $40.50 ($81 allowed x 50% coinsurance). The 
total billed amount for the extraction for tooth #3 was $250 and the total allowed amount was $85 leaving the 
difference of $165 ($250 billed - $85 allowed). The total coinsurance amount for the extraction for tooth #3 
was $46.75 ($85 allowed x 55% coinsurance). The total billed amount for the extraction for tooth #24 was 
$250 and the total allowed amount was $85 leaving the difference of $165 ($250 billed - $85 allowed). The 
total coinsurance amount for the extraction for tooth #24 was $46.75 ($85 allowed x 55% coinsurance). The 
total amount of the difference between the billed and allowed amounts was $411 ($81 allowed + $165 allowed 
+ $165 allowed). The total amount for the coinsurance was $134 ($40.50 coinsurance + $46.75 coinsurance + 
$46.75 coinsurance). The limited oral evaluation is not covered under the Plans dental benefit. 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 intraoral radiographic images (D0210) and the extractions (D7140) 
for tooth #3 and #24 and to pay for the limited oral evaluation (D0140) provided by an out-of-network provider 
on November 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on December 7, 2022. 
 
You asked the Plan to pay for the consultation. You say that you received a referral from your dentist for a 
second opinion on a dental procedure. You also say that this provider is in-network, performed the services 
which are all covered, what could be missing. The Plan denied your request. The Plan says this service is not 
covered under the benefit package. 
 
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 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on December 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the unspecified removable prosthodontic procedure 
(D5899) provided on January 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that it was medically necessary for you to get 
the dental procedures done and you are appealing the denied service. The Plan denied your request. The Plan 
says your maximum dental 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 on March 3, 2023, which was processed prior to this claim the Plan paid $149 for dental services. On 
January 24, 2023, after the Plan reprocessed this claim the Plan paid $351 for the dental service. For the year of 
2023 the Plan paid $500 ($149 paid + $351 paid) for dental services. Therefore, your maximum dental 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 more for the unspecified removable prosthodontic procedure (D5899) provided on 
January 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the INR result interpretations provided on 
November 23, 2022, and January 3, 2023. 
 
You asked the Plan to waive the copayments for the INR result interpretations. You say that this should be 
considered a preventative service 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 2022 contract with the Plan clearly says that you must pay a 
$25 copayment for in-network diagnostic tests and procedures. Your 2023 contract with the Plan also clearly says that you must pay a $25 copayment for in-network diagnostic tests and procedures. 
 
You have been asked to pay $11.49 for the INR result interpretation provided on November 23, 2022, which is 
less than the standard $25 copayment. You have been asked to pay $11.34 for the INR result interpretation 
provided on January 3, 2023, which is less than the standard $25 copayment. These items/services fall within 
the outpatient diagnostic tests and therapeutic services benefit category. You have been asked to pay a total of 
$22.83 ($11.49 copayment + $11.34 copayment = $22.83). 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 copayments 
for the INR result interpretations provided on November 23, 2022, and January 3, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from September 1, 
2020, to September 19, 2020. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that the enrollee's SNF care was 
discontinued stating there was no longer a need for skilled nursing care, but the enrollee's medical diagnosis 
required continued skilled nursing care. 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 per day for days 1 to 20 and a $178 copayment per day for days 21 to 100 for SNF 
care.  The enrollee has been asked to pay a $534 copayment for a SNF stay ($178 per day x 3 days = $534). 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 September 1, 2020, to September 19, 2020.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oxygen and oxygen supplies (A0422) provided on November 
21, 2022. 
 
You asked the Plan to pay for the ambulance supplies. You say that the patient needed surgical services that 
they did not have at the first hospital. The Plan denied your request. The Plan says per review of the 
Ambulance Fee Schedule, code A0422 is not payable by Medicare, so no reimbursement is allowed. 
 The Plan must follow Medicare rules. Medicare rules say that ambulance supplies are considered part of the 
general ambulance service and payment for them is included in the payment rate for the transport. Therefore, 
we decided that the Plan does not have to pay for oxygen and oxygen supplies (A0422) provided on November 
21, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on October 22, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
ambulance came to your house and you were in diabetic shock. You also say that your husband put lozenges in 
your mouth and you were choking on them. The Plan denied your request. The Plan says these services are not 
a covered benefit. 
 
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 October 22, 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 the ambulance response and treatment with no 
transport provided on October 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composites (D2393, D2330, D2394) provided on 
February 20, 2023. 
 
You asked the Plan to pay for resin-based composites. You say that you would like this Plan to pay for this. 
The Plan denied your request. The Plan says the rendered dental services are not covered. 
 
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 resin-
based composites (D2393, D2330, D2394) provided on February 20, 2023.