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

 
We decided that the Plan does not have to pay for the consultation (D9310) provided on March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you checked and made sure your provider was 
in-network. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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 
consultation (D9310) provided on March 20, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an implantable auricular neurostimulator (64555, 
L8679). 
 
You asked the Plan to pre-approve an implantable auricular neurostimulator. You say that this is not an 
investigational procedure. The provider also says that this is not a spinal cord stimulator nor is it considered 
acupuncture. The Plan denied your request. The Plan says this procedure is not medically necessary. 
 
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 an implantable auricular 
neurostimulator. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found that this device is considered experimental for back 
pain. It is the subject of an ongoing clinical trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an implantable auricular neurostimulator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an implantable auricular neurostimulator (64555, L8679).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92012) 
provided on June 29, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92012). You say that you feel you 
should not owe the copayment when you were not given satisfactory 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 $35 
copayment for a medical eye examination.  
 
 
  You have been asked to pay a $35 copayment for a medical eye examination (92012). This item/service falls 
within the medical eye examination 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 
medical eye examination (92012) provided on June 29, 2022.  
 
Your complaint about the potentially unsatisfactory service is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown and pontic (D6750, D6240) provided on April 25, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 crown 
and pontic (D6750, D6240) provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional intra-oral x-rays, bitewing x-rays, adjunctive pre-
diagnostic test, and oral hygiene instructions (D0273, D0220, D0431, D0230, D1330) provided on March 29, 
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 intra-oral x-rays and bitewing 
x-rays has already been exhausted. Coverage for the adjunctive pre-diagnostic test and oral hygiene instructions 
denied correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, adjunctive pre-diagnostic tests and oral 
hygiene instructions are not among those covered under this benefit. 
 
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 March 28, 2023. 
Therefore, we decided that the Plan does not have to pay for additional intra-oral x-rays, bitewing x-rays, 
adjunctive pre-diagnostic test, and oral hygiene instructions (D0273, D0220, D0431, D0230, D1330) provided 
on March 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation (D7953) 
provided on April 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure should be covered up to the 
annual maximum allowance for dental services. The Plan denied your request. The Plan says this service is not 
a covered benefit under your dental 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 bone 
replacement graft for ridge preservation (D7953) provided on April 3, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 48 additional trips. 
 
You asked the Plan to pre-approve 48 additional trips. You say that you are a methadone patient, and need 
appointments 4 mornings per week. The Plan denied your request. The Plan says 48 additional trips would 
exceed your benefit limit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. The record shows that you have used 46 
trips as of June 19, 2023, and you had 2 trips left. Based on this information, we decided that you have, or will 
have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that 
the Plan does not have to pre-approve 48 additional trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pontic (D6240) for tooth #13 and retainer crowns 
(D6750) for tooth #12 and #14. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary 
because you are in intense pain when you bite. 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 the Plan pre-approved pontics (D6240) for tooth #4 and #5 and retainer crowns (D6750) for tooth #3 and 
#6 on January 25, 2023; therefore, your benefit for the requested items or services was exhausted on the date of 
approval of January 25, 2023. Therefore, we decided that the Plan does not have to pre-approve a pontic 
(D6240) for tooth #13 and retainer crowns (D6750) for tooth #12 and #14.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Xarelto. 
 
You asked the Plan to pre-approve the medication. You say that you prefer Xarelto over other medication. 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 pre-approve Xarelto.  
 
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 pre-approve a complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve the complete denture - maxillary. The Plan denied your request. The Plan 
says your benefit for the complete denture - maxillary  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 complete denture - maxillary  was exhausted on date of service October 27, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740) and to pay for the core buildup 
(D2950) for tooth #27 provided by an out-of-network provider on February 8, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you paid for the core buildup, and you 
would like the Plan to cover it. 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 denial of payment for the core buildup 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. The total amount billed for the crown (D2740) was $1,418 and the allowed amount was $641 leaving a 
difference of $777. The total coinsurance amount was $480.75 ($641 allowed x 75% coinsurance). The total 
amount you are responsible for the crown is $1,257.75 ($777 difference + $480.75 coinsurance). 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment along with the coinsurance for the crown (D2740). This cost sharing is a contractual obligation you 
agreed to pay when you enrolled in the Plan. The core buildup is not covered under the Plans dental benefit. 
Therefore, we decided that the Plan does not have to pay more for the crown (D2740) and to pay for the core 
buildup (D2950) for tooth #27 provided by an out-of-network provider on February 8, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for incontinence supplies provided on October 8, 2022.  
 
You asked the Plan to pay for incontinence supplies. You say that you would like reconsideration because the 
requested incontinence supplies are medically necessary. The Plan denied your request. The Plan says the 
requested incontinence supplies are not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pay for incontinence supplies provided on 
October 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92012) 
provided on April 18, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92012). You say that you feel you 
should not owe the copayment when you were not given satisfactory 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 $35 
copayment for a medical eye exam.  
 
 
  You have been asked to pay $35 copayment for a medical eye examination (92012). This item/service falls 
within the medical eye exam 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 medical 
eye examination (92012) provided on April 18, 2022.  
 
Your complaint about the potentially unsatisfactory service is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a re-cement or re-bond of a fixed partial denture (D6930) 
provided on April 5, 2022. 
 
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 they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  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 re-
cement or re-bond of a fixed partial denture (D6930) provided on April 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a toilet rail. 
 
You asked the Plan to pre-approve a toilet rail. You say that you would like reconsideration because the 
requested toilet rail is medically necessary. The Plan denied your request. The Plan says the requested toilet rail 
is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that grab bars are not covered because 
they are not primarily medical in nature.  
 
While a grab bar may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a toilet rail.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of implant body (D6010) for 
tooth #4 and #6. 
 
You asked the Plan to pre-approve the dental services. You say that the procedures have not been performed 
this year and the treatment is incomplete. 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 the Plan pre-approved the surgical placement of implant body (D6010) for tooth #12 and #13 on January 
26, 2023; therefore, your benefit for the requested items or services was exhausted on the date of approval of 
January 26, 2023. Therefore, we decided that the Plan does not have to pre-approve the surgical placement of 
implant body (D6010) for tooth #4 and #6.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a cone beam (D0367), the guided tissue regeneration 
(D3432), a bone graft (D3428), the evaluation for deep sedation (D9219) for tooth #5. 
 
You asked the Plan to pre-approve the dental services. You say that you have an infection and pain in your gum 
and the dental services are necessary. The Plan denied your request. The Plan says the denial of authorization 
for these services is correct, because the cone beam, the guided tissue regeneration, a bone graft, the evaluation 
for deep sedation 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. 
 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 a 
cone beam (D0367), the guided tissue regeneration (D3432), a bone graft (D3428), the evaluation for deep 
sedation (D9219) for tooth #5.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
April 11, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that this appointment was 
set up for a routine eye examination. You also say you did not go in for problems with your eyes. 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 medical eye exam. 
 
You have been asked to pay a $40 copayment for a medical eye examination. This item/service falls within the 
medical eye exam 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 medical eye 
examination provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation and intraoral x-rays (D0140, 
D0220, D0230) provided on March 21, 2023. 
 
You asked the Plan to pay more 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 you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. Your benefit for the intraoral x-ray 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 March 21, 2023. 
 
You have also 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 limited oral evaluation and intraoral x-rays 
(D0140, D0220, D0230) provided on March 21, 2023.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on December 3, 2022. 
 You asked the Plan to pay for the ambulance services. You say that the enrollee was not in hospice at the time 
of transport. The Plan denied your request. The Plan says Original Medicare is responsible for payment. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on December 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination (92012) 
provided on July 15, 2022. 
 
You asked the Plan to waive the copayment for a medical eye examination (92012). You say that you feel you 
should not owe the copayment when you were not given satisfactory 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 $35 
copayment for a medical eye examination.  
 
 
  You have been asked to pay a $35 copayment for a medical eye examination (92012). This item/service falls 
within the medical eye examination 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 
medical eye examination (92012) provided on July 15, 2022.  
 
Your complaint about the potentially unsatisfactory service is not a valid appeal for medical coverage. This part 
of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a 
decision about these types of complaints.