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

 
We decided that the Plan does not have to pay for the treatment of a root canal obstruction; non-surgical access 
(D3331) provided on July 21, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the treatment of a 
root canal obstruction; non-surgical access (D3331) provided on July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve non-emergency transportation by car. 
 
You asked the Plan to pre-approve the non-emergency transportation by car. You say that you are seeking 
reconsideration for coverage of non-emergency transportation by car between your home and 4 medical 
appointments. You also say that you have a diagnosis of multiple scoliosis and you need multiple 
transportation. The Plan denied your request. The Plan says the requested service is not covered by Medicare or 
offered as a supplemental benefit by the plan. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We looked at your request, the records in the case file and the rules. You asked the Plan to pre-approve non-
emergency transportation by car. Based on this information we decided that the Plans rules for coverage have 
not been met. Therefore, we decided that the Plan does not have to pre-approve non-emergency transportation 
by car.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildups, including any pins when required  
(D2950 x 2) provided on July 18, 2023. 
 
You asked the Plan to pay for these items. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says these items are not covered under the supplemental 
dental policy.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the items provided are not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the core buildups, 
including any pins when required (D2950 x 2) provided on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213). 
 
You asked the Plan to pre-approve the maxillary partial denture. You say that you lost your denture when you 
were in the hospital in August of 2023 and are appealing the denial decision. The Plan denied your request. The 
Plan says your benefit for the requested 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 date of service October 14, 2021. Therefore, we 
decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure (D4999), and oral 
hygiene instructions (D1330), provided on July 28, 2023, to August 1, 2023. 
 
You asked the Plan to pay for D4999 and D1330. You say that you were unaware that a deep cleaning was not 
covered. The Plan denied your request. The Plan says the denied 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 
unspecified periodontal procedure (D4999), and oral hygiene instructions (D1330), provided on July 28, 2023, 
to August 1, 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 March 
6, 2021. 
 
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 the claim was 
filed untimely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for the dental services was not filed until July 31, 2023. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panel testing (87481, 87640, 87652, 87798, and 87799) 
provided on July 12, 2023. 
 
You asked the Plan to pay for procedure codes 87481, 87640, 87652, 87798, and 87799. You say that you 
would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the 
services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 87481, 87640, 87652, 87798, and 87799 are not supported in the medical record. 
Specifically, a panel was performed and there is a more appropriate singular code for the services. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the panel testing (87481, 87640, 87652, 87798, and 87799) 
provided on July 12, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for an in-network hospital bed provided on March 9, 
2023. 
 
You asked the Plan to reimburse you $174.08 for a hospital bed. You say that you needed this item because 
you had hip surgery. Your provider sent a letter stating this item was medically necessary. You want to be 
reimbursed for the out-of-pocket charge for this. 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 durable medical equipment (DME) and related supplies.  
 
 You were asked to pay $174.08 for a hospital bed. This item/service falls within the durable medical equipment 
(DME) 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 reimburse you for an in-network 
hospital bed provided on March 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on February 3, 2023. 
 
You asked the Plan to pay for dental services. You say that a representative switched coverage on the enrollee. 
The Plan denied your request. The Plan says these services have been correctly denied. 
 
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 
the enrollees teeth or the structures directly supporting the enrollees 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 dental 
services provided on February 3, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pacemaker insertion procedure provided 
on May 11, 2023, to May 12, 2023. 
 
You asked the Plan to waive the coinsurance for a pacemaker insertion procedure. You say that you should not 
have to pay so much for this 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 contract with the Plan clearly says that you must pay 5% 
coinsurance for outpatient surgery, including services provided at hospital outpatient facilities.  
 
You have been asked to pay $478.82, which is 5% coinsurance of the allowed amount for a pacemaker 
insertion procedure ($9,576.42 allowed amount x 5% = $478.82). This item/service falls within the outpatient 
surgery, including services provided at hospital outpatient facilities 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 a pacemaker insertion procedure provided on May 11, 2023, to May 12, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve needle electromyography to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve needle electromyography to be provided by an OON provider. You say that 
the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are 
able to provide these services. Therefore, coverage criteria have not been met. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
needle electromyography to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a labial veneer (D2960) provided on April 25, 2023. 
 
You asked the Plan to pay for D2960. You say that this was not a cosmetic procedure. 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 a labial 
veneer (D2960) provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive series of radiographic images (D0210) 
provided on August 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have not had this done in over a year. 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 October 4, 2021. Therefore, we decided that the Plan does not have to pay for comprehensive series of radiographic images 
(D0210) provided on August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on August 2, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 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 service provided was exhausted on date of service January 26, 2022.  
  
 
 
 
 
Specifically, the Plans contract states that one intraoral-comprehensive series of radiographic images is 
covered every three years. You previously received this service on January 26, 2022, less than three years prior, 
which was paid for by the Plan. Therefore, you have exhausted the allowable benefit for this service. Therefore, 
we decided that the Plan does not have to pay for the intraoral-comprehensive series of radiographic images 
(D0210) provided on August 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) 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 June 6, 2023. Therefore, 
we decided that the Plan does not have to pay for a crown and core buildup services (D2740, D2950) provided 
on June 6, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 16, 2023, to May 
23, 2023. 
 You asked the Plan to pay for the home health services. You say that you do not believe that a NOA is 
required. The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As a result, no payment can be made on this claim. 
Therefore, we decided that the Plan does not have to pay for home health services provided from May 16, 
2023, to May 23, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a total electric hospital bed. 
 
You asked the Plan to pre-approve a total electric hospital bed. You say that the enrollee had a total electric 
bed, but it was replaced with a partial electric one. Due to your back surgery, you cannot get the enrollee out of 
bed safely with a partial electric bed. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to pre-approve a total electric hospital 
bed.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve FreeStyle Lite test strips. 
 
You asked the Plan to pre-approve the FreeStyle Lite test strips. The Plan denied your request. The Plan says 
only the preferred brand products listed in the EOC are covered and the supporting statement provided by the 
prescriber does not indicate why our preferred product is not clinically appropriate to treat the enrollee's 
condition. 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. The Plan has verified with the physician's office that the enrollee is 
able to use the preferred diabetic testing supplies and will reach out to the enrollee and send a new prescription 
to their preferred pharmacy. According to the EOC, the requested brand is not a preferred brand for the 
FreeStyle Lite test strips.. Therefore, we decided that the Plan does not have to pre-approve FreeStyle Lite test 
strips.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the chiropractic manipulative treatment 
provided by a chiropractor on June 22, 2023, to July 14, 2023. 
 
You asked the Plan to waive the copayment for chiropractic manipulative treatment. You say that you did not 
know the provider was out-of-network, therefore, you feel this should be processed as in-network. 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 50% 
coinsurance for out-of-network Medicare-covered chiropractic benefits (based on the Medicare allowable 
amount). 
 
You have been asked to pay a total of $90 for chiropractic manipulative treatment. 
 
Date of Service Service Allowed Amount Standard Cost Member Liability 
June 22, 2023 Chiropractic care $45 50% $22.50 
June 29, 2023 Chiropractic care $45 50% $22.50 
July 7, 2023 Chiropractic care $45 50% $22.50 
July 14, 2023 Chiropractic care $45 50% $22.50 
TOTAL:    $90.00 
 
These items/services fall within the chiropractic 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 the chiropractic manipulative treatment provided by a chiropractor on June 22, 
2023, to July 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drug provided on August 2, 2023. 
 
You asked the Plan to pay for the medication. You say that you were charged for medication on the days you 
went to the emergency room, and you are not sure why. 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 drug provided 
on August 2, 2023.  
 
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for deluxe frames (V2025), single vision lenses (V2100) and 
polycarbonate lenses (V2784) provided on June 20, 2023.  
You asked the Plan to pay for deluxe frames (V2025), single vision lenses (V2100) and polycarbonate lenses 
(V2784). You say that you have never had to pay for glasses before. You also say that you have also never 
heard of the Plan vision network provider. The Plan denied your request. The Plan says the claim was from a 
provider who is not in our network. The Plan also says that they do not cover this out-of-network vision care 
service. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the eyewear is obtained through a Plan vision network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that for routine eyewear and routine eye 
examination, you must use a Plan Vision network provider. The record shows that the eyewear was provided 
by a provider who is not in the Plan vision network. Based on this information, we decided that the Plan's rules 
for coverage of deluxe frames (V2025), single vision lenses (V2100) and polycarbonate lenses (V2784) have 
not been met. Therefore, we decided that the Plan does not have to pay for deluxe frames (V2025), single 
vision lenses (V2100) and polycarbonate lenses (V2784) provided on June 20, 2023.