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

 
We decided that the Plan does not have to pay for a tooth extraction provided on January 9, 2023. 
 
You asked the Plan to pay for a tooth extraction . 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 a tooth 
extraction provided on January 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inlay resin-based composites (D2650) for tooth #11 and 
#20 provided on February 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
inlay resin-based composites are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 inlay 
resin-based composites (D2650) for tooth #11 and #20 provided on February 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided on 
September 27, 2022, to October 03, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you are on a new 
insurance and want to use their benefits. 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 $300 
copayment for inpatient hospital care. 
 
You have been asked to pay a $300 copayment for the inpatient hospital stay. This item/service falls within the 
inpatient hospital care 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 inpatient 
hospital stay provided on September 27, 2022, to October 03, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that these services were medically necessary. 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 on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prefabricated post and core (D2954), provided on January 
31, 2023. 
 
You asked the Plan to pay for D2954. You say that you needed this dental work because your crown fell off. 
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 (D2954), provided on January 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), prophylaxis 
(D1110), and a complete series of radiographic images (D0210), provided on January 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told that this provider accepted your 
insurance. 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 comprehensive oral evaluation (D0150), prophylaxis (D1110), and a complete series of 
radiographic images (D0210), provided on January 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on February 24, 
2023, to March 02, 2023.  
 
You asked the Plan to waive the copayment for inpatient hospital stay. You say that you kept asking the facility 
to release you but would not let you go. 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 $295 
copayment per day, days 1 to 6 for inpatient hospital stay. Covered services include mental health care services 
that require a hospital stay. There were 6 days. 6 x $295 = $1,770. Therefore, results in the total cost sharing 
amount of $1,770. 
 You have been asked to pay a $295 copayment per day for inpatient hospital stay. This item/service falls within 
the inpatient service in a psychiatric hospital benefit category. This means that you have been asked to pay the 
correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment 
for inpatient hospital stay on February 24, 2023, to March 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) and pay for the interim partial denture (including retentive/clasping materials, 
rests, and teeth), mandibular (D5821) provided on November 30, 2022.  
 You asked the Plan to pay more for the dental services. You say that you accept that the dentist is out-of-
network but your insurance makes such small payments. You also say that you wish to dispute this date of 
service. 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 Plan also 
says that service D5821 is not listed as 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for the extraction, erupted tooth or exposed root (D7140). This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. The interim partial denture (D5821) is not among those 
services covered under this benefit. Therefore, we decided that the Plan does not have to pay more for 
extraction, erupted tooth or exposed root (elevation and/or forceps removal) (D7140) and pay for the interim 
partial denture (including retentive/clasping materials, rests, and teeth), mandibular (D5821) provided on 
November 30, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a specialist visit provided on January 18, 
2023. 
 
You asked the Plan to waive the copayment for a specialist visit. You say that you do not think that there is a 
copayment 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 a $40 
copayment for each covered telehealth visit or consultation in an outpatient location with a specialist. 
 
You have been asked to pay a $40 copayment for a specialist visit. This item/service falls within the each covered telehealth visit or consultation in an outpatient location with a specialist 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 visit provided on January 18, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections provided on October 31, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you disagree with the coinsurance. 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for injections. This item/service falls within the Medicare Part B 
prescription drugs 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 injections provided 
on October 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the know error DNA Specimen Provenance Assay billed 
with codes 81266 and 81265 provided on June 1, 2022. 
 
You asked the Plan to pay for the know error DNA Specimen Provenance Assay. You say that you would like 
the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says this testing is not 
covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the know error DNA Specimen Provenance 
Assay is a statutorily excluded test. Therefore, we decided that the Plan does not have to pay for the know error 
DNA Specimen Provenance Assay billed with codes 81266 and 81265 provided on June 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a standard wheelchair provided on August 02, 2021, to 
October 30, 2021. 
 
You asked the Plan to pay for a standard wheelchair. You say that the services should be covered. 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 standard wheelchair 
provided on August 02, 2021, to October 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) and a panoramic 
radiographic image (D0330) provided on December 8, 2022, and December 9, 2022. 
 You asked the Plan to pay for the dental services. You say that you would like to be reimbursed for the 
payments you have made on the denied dental services. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 that the Plan paid for a full mouth x-ray on May 28, 2020; therefore, your benefit for the panoramic 
radiographic image was exhausted on the date of service of May 28, 2020. The record shows that the Plan paid 
for an emergency diagnostic exam on December 8, 2022; therefore your benefit for the limited oral evaluation 
was exhausted on the date of service of December 8, 2022. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140) and a panoramic radiographic image (D0330) provided on 
December 8, 2022, and December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0364), the pulp vitality tests (D0460), an 
unspecified preventive procedure (D1999), and a consultation (D9310) provided on December 21, 2022. 
 
You asked the Plan to pay for the dental services. You say that the consultation was with a specialist to 
determine if a root canal could be done, and you do not understand why the Plan is not paying for the dental 
services. The Plan denied your request. The Plan says the denial of payment for these services is correct, 
because the cone beam, pulp vitality tests, unspecified preventive procedure, and consultation are not covered 
by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 cone 
beam (D0364), the pulp vitality tests (D0460), an unspecified preventive procedure (D1999), and a consultation 
(D9310) provided on December 21, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal fusion surgery. 
 
You asked the Plan to pre-approve spinal fusion surgery. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 spinal fusion surgery. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the medical records do not show any evidence of spinal instability. Also, a recent 12-
week trial of physical therapy has not been tried and failed. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of spinal fusion surgery have not been met. Therefore, we decided that the Plan 
does not have to pre-approve spinal fusion surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2392) provided by an out-of-
network provider on January 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was an emergency. 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 (D2392) provided by an out-of-network provider on January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on January 21, 2023. 
 
You asked the Plan to pay for an extraction. 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 an 
extraction (D7210) provided on January 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit for the evaluation and management provided on 
January 03, 2023. 
 
You asked the Plan to pay for a home visit for the evaluation and management. You say that the services 
should be covered. 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 home visit for the 
evaluation and management provided on January 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on March 7, 2023. 
 
You asked the Plan to pay for D7210. You say that you do not understand what dental plan does not cover 
extractions. The Plan denied your request. The Plan says the enrollee is not enrolled in the optional 
supplemental dental plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for an extraction (D7210) provided 
on March 7, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for  diabetic supplies provided on December 
15, 2022. 
 
You asked the Plan to waive the copayment for  diabetic supplies. You say that you had to pay copayments up 
front, and you reached your out-of-pocket maximum so you should not be paying any claims. 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 $100 
deductible, $500 maximum out-of-pocket and 20% coinsurance for diabetes self-management training, diabetic 
services and supplies.  
 You have been asked to pay $100 deductible, $500 maximum out-of-pocket and 20% coinsurance for diabetic 
supplies. This item/service falls within the diabetes self-management training, diabetic services, and 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 copayment for  diabetic supplies provided on 
December 15, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the abdominal ultrasound provided on 
January 04, 2023. 
 
You asked the Plan to waive the copayment for the abdominal ultrasound. You say that all tests should be 
fulled 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 $100 
copayment for outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $100 copayment for the abdominal ultrasound. This item/service falls within the 
outpatient diagnostic tests, including ultrasounds 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 abdominal ultrasound provided on January 04, 2023.