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

 
We decided that the Plan does not have to pay more for periodontal scaling and root planing - four or more 
teeth per quadrant (D4341), and comprehensive periodontal evaluation - new or established patient (D0180) 
provided on December 29, 2022, to January 9, 2023. 
 
You asked the Plan to pay more for the dental services represented by codes D4341 and D0180.. You say that 
the Plan did not pay correctly and you were quoted one rate at time of service only to have it nearly double the 
amount due after the services were rendered because the provider was out-of-network. 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. 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. 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 periodontal scaling and root planing - four or 
more teeth per quadrant (D4341), and comprehensive periodontal evaluation - new or established patient 
(D0180) provided on December 29, 2022, to January 9, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0003A billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 0003A. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed.  
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 0003A is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 0003A have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 0003A billed for date of service May 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a replacement of replaceable part of attachment (D7953) 
provided on January 5, 2023. 
 
You asked the Plan to pay for D7953. You say that you feel like this should be covered. The Plan denied your 
request. The Plan says the rendered 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 
replacement of replaceable part of attachment (D7953) provided on January 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and core buildup (D2950) for tooth 
#14 provided by an out-of-network provider on December 19, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told by the provider that the 
procedures would be covered by the Plan, and you should not be responsible for the charges. 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. 
 
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. 
 
  For the crown the total billed amount was $981 and the allowed amount was $595 leaving a difference amount 
of $386 ($981 billed - $595 allowed). The total billed for the core buildup was $228 and the allowed amount 
was $83 leaving a difference amount of $145 ($228 - $83 allowed). The total amount for the difference in the 
dental services was $531 ($386 difference + $145 difference). You have been asked to pay 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. Therefore, we decided that the Plan does not have 
to pay more for a crown (D2740) and core buildup (D2950) for tooth #14 provided by an out-of-network 
provider on December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on 
January 20, 2023. 
 
You asked the Plan to pay for the dental service. You say that the enrollee was told by the facility that the Plan 
covered all the procedures and that they would owe nothing. 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 complete series of radiographic images (D0210) on January 20, 2023; therefore, the 
enrollees benefit for the requested item or service was exhausted on the date of service of January 20, 2023. 
Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on January 20, 2023.
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 September 26, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that it has 
never been your understanding that a 911 call is a defined need to go to an emergency room. 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 September 26, 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 September 26, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services billed on October 11, 2021. 
 
You asked the Plan to pay for the inpatient hospital services provided. You say that the claim was billed 
correctly and should be paid. The Plan denied your request. The Plan says documentation does not support 
services as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the inpatient hospital services provided 
have been met. Specifically, complete medical records for the billed services were not provided for review. 
Therefore, we decided that the Plan does not have to pay for inpatient hospital services billed on October 11, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the repair or replacement of a broken clasp (D5630) 
and replacement of a broken tooth (D5640) provided on September 16, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting reconsideration of the 
denial decision. The Plan denied your request. The Plan says the claim processed correctly in accordance with 
your dental plan 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, you have been asked to pay the 
difference between the out-of-network providers charges and the Plans payment, in addition to 50% of the 
allowed amount after the $100 deductible is met for the services received. Therefore, we decided that the Plan 
does not have to pay more for the repair or replacement of a broken clasp (D5630) and replacement of 
a broken tooth (D5640) provided on September 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crowns (D2740), core buildup (D2950), desensitizing 
rinse (D9910) and occlusal guard (D9944). 
 
You asked the Plan to pre-approve crowns, core buildup, desensitizing rinse, and occlusal guard. You say that 
these 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 pre-approve 
crowns (D2740), core buildup (D2950), desensitizing rinse (D9910) and occlusal guard (D9944).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve deep sedation/general anesthesia  first 15 minutes 
(D9222), and each subsequent 15 minute increment (D9223). 
 
You asked the Plan to pre-approve the deep sedation/general anesthesia  first 15 minutes and each subsequent 
15 minute increment. You say that the dentist said you have to go to oral surgery as the teeth have to come out 
and you have been on pain medication. The Plan denied your request. The Plan says the services are not 
covered under your dental benefit 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 pre-approve deep 
sedation/general anesthesia  first 15 minutes (D9222), and each subsequent 15 minute increment (D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mileage expenses made from January 3, 2023, to January 
18, 2023. 
 
You asked the Plan to pay for the mileage expenses. You say that the mileage expenses were related to visits as 
part of your kidney transplant care. The Plan denied your request. The Plan says you cannot use your transplant 
travel benefit for this claim to be reimbursed because you live in the same service area where you had services 
rendered. 
 
The Plan must follow Medicare rules. Medicare rules say that in any circumstance in which an MA plan 
provides transplant services at a more distant location, the MA plan must provide reasonable transportation for 
the enrollee and a companion to the distant facility. 
 
 
 
 
 We looked at the file and Medicare rules. The record shows that the provider's offices you went to are all 
within the three designated counties that are within the Plan's service area. Based on this information, we 
decided that Medicare rules for coverage of the mileage expenses have not been met. Therefore, we decided 
that the Plan does not have to pay for the mileage expenses made from January 3, 2023, to January 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible applied for the gym membership (99199) 
purchased on December 2, 2022. 
 
You asked the Plan to waive the deductible. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the deductible has been applied correctly to 
the gym membership purchased from an out-of-network provider. 
  
 
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 after satisfying a $500 deductible for health and wellness programs purchased from an out-of-
network provider.  
 
You have been asked to pay a $131 deductible for the gym membership purchased from an out-of-network 
provider. This is the amount billed by the provider and allowed by the Plan for this service. Health and 
Wellness programs that qualify for benefit coverage from an out-of-network provider are subject to a 50% 
coinsurance after satisfying a $500 deductible. The record shows that you have not previously met the yearly 
deductible. 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 deductible applied for the gym membership (99199) 
purchased on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99291 billed for date of service June 11, 2022. 
 
You asked the Plan to pay for code 99291. You say that this service was billed correctly and the records 
support payment. The Plan denied your request. The Plan says the medical records do not support the billing of 
this code. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is Critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, code 99291 is a time-based 
code. This means that the medical records must contain evidence that 30-74 minutes were spent on critical care 
services on the date of service billed.  In this case, the medical record from June 11, 2022, is lacking any time details that would be needed to confirm that the 30-74-minute requirement had been met. Based on this 
information, we decided that Medicare rules for coverage of code 99291 have not been met. Therefore, we 
decided that the Plan does not have to pay for code 99291 billed for date of service June 11, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the copayments applied to the chiropractic 
manipulative treatments (98940) provided from January 19, 2022, through December 19, 2022. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the wallet benefit does not apply to items and 
services that are covered by your medical benefits. 
 
The Plan must follow Medicare rules. However, the Plan provides supplemental coverage for a wallet benefit 
to cover the cost of certain health related items and services that Original Medicare does not consider medically 
necessary.  
 
You do not meet criteria for coverage of the copayments applied in this case as items and services that are 
covered by your medical benefits are excluded from the Wallet Benefit. The chiropractic services provided in 
this case are a covered benefit by Medicare and the Plan. The Plan provides supplemental coverage for a wallet 
benefit to cover the cost of certain health related items and services that Original Medicare does not consider 
medically necessary.  
  
Therefore, we decided that the Plan does not have to issue reimbursement for the copayments applied to the 
chiropractic manipulative treatments (98940) provided from January 19, 2022, through December 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown - porcelain/ceramic (D2740) provided on January 17, 
2023. 
 
You asked the Plan to pay for dental services. You say that you would like reimbursement even though the 
provider was out-of-network. The Plan denied your request. The Plan says you did not purchase the optional 
dental package. Therefore, the service cannot be covered. 
 
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 crown - porcelain/ceramic 
(D2740) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on October 13, 2022, to 
November 8, 2022. 
 
You asked the Plan to pay for an extraction, collection and application of autologous blood concentrate 
product, mandibular partial denture. You say that this should be covered. The Plan denied your request. The 
Plan says these are not covered services. You asked the Plan to pay for bitewing x-rays, comprehensive oral 
evaluation, and prophylaxis. The Plan says that services provided by out of network providers are 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 the dental 
services provided on October 13, 2022, to November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive series of radiographic images (D0210) 
provided on January 20, 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 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 September 12, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive series of radiographic images 
(D0210) provided on January 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Contour Next test strips. 
 
You asked the Plan to pre-approve Contour Next test strips. You say that you are appealing the denied strips. 
The Plan denied your request. The Plan says only the preferred brand products listed in the EOC are covered. 
  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. According to the EOC, the requested brand is not a preferred brand 
for blood glucose test strips. Therefore, we decided that the Plan does not have to pre-approve Contour Next 
test strips.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on September 26, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these services are separately 
payable. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related 
laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
September 26, 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 
January 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told this provider was not in-
network. The Plan denied your request. The Plan says the dental services were received from an out-of-network 
provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for dental services provided by an out-of-network provider on January 9, 2023.