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

 
We decided that the Plan does not have to pay for dental services provided on February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was 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 February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750), bifocal lenses (V2200), and 
photochromatic lenses (V2744) provided on March 18, 2023. 
 
You asked the Plan to pay for anti-reflective coating (V2750), bifocal lenses (V2200), and photochromatic 
lenses (V2744). You say that went back for the second re-examination prescription. You also say that the 
provider told you there was no charge. The Plan denied your request. The Plan says the maximum benefit has 
been exceeded. 
 
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 a $300 benefit toward the purchase and fitting of eyeglasses and pair of lenses or 
contact lenses (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules also say there is a $300 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The record shows this 
benefit was exhausted on March 18, 2023. Based on this information, we decided that the Plan's rules for 
coverage of anti-reflective coating (V2750), bifocal lenses (V2200), and photochromatic lenses (V2744) have 
not been met. Therefore, we decided that the Plan does not have to pay for anti-reflective coating (V2750), 
bifocal lenses (V2200), and photochromatic lenses (V2744) provided on March 18, 2023.  
 
Your complaint about the potentially poor service you received from the provider 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 cone beam CT capture and interpretation (D0367), and 
therapeutic drug injection (D9610) provided on April 17, 2023. 
 
You asked the Plan to pay for cone beam CT capture and interpretation and therapeutic drug injection. 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 cone 
beam CT capture and interpretation (D0367), and therapeutic drug injection (D9610) provided on April 17, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT provided on May 18, 2023. 
 
You asked the Plan to pay for cone beam CT. 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 cone 
beam CT provided on May 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on April 19, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you were not 
aware the scan was not a low dose CT. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic tests 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. The total you owe is $125.95, which is less than the standard copayment for a 
diagnostic CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tooth root removal (D7250) provided on March 8, 2023. 
 
You asked the Plan to pay for D7250. You say that you thought this service was free. The Plan denied your 
request. The Plan says the denied 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 tooth root 
removal (D7250) provided on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), a two-dimensional 
(2D) oral/facial photographic image (D0350) and oral hygiene instructions (D1330) provided on February 7, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the provider advised you to get treatment from a 
professional. You also say that the Plan accepted the later dental visits you had and denied the correct claim 
you submitted. The Plan denied your request. The Plan says your benefit for a comprehensive oral evaluation 
(D0150) has already been exhausted. The Plan also says that two-dimensional (2D) oral/facial photographic 
images (D0350) and oral hygiene instructions (D1330) are excluded from this 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, certain limitations apply. The record 
shows your benefit for a comprehensive oral evaluation was exhausted on date of service February 22, 2023. 
Also, though the Plan offers a dental benefit in excess of Medicare coverage, two-dimensional (2D) oral/facial 
photographic images (D0350) and oral hygiene instructions (D1330) are not among those covered under this 
benefit. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
a two-dimensional (2D) oral/facial photographic image (D0350) and oral hygiene instructions (D1330) 
provided on February 7, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance image (MRI) 
provided on April 22, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance image (MRI). You say that you signed 
paperwork stating your copayment would be $0. 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 $285 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $285 copayment for a magnetic resonance image (MRI). This item/service falls 
within the outpatient diagnostic tests 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. The total you owe is $196.03, which is less than the standard copayment for an 
MRI. Therefore, we decided that the Plan does not have to waive the copayment for a magnetic resonance 
image (MRI) provided on April 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says you have a $0 copay up to the $2,000 allowance for all covered dental services. You pay 
100% of charges beyond the $2,000 allowance or if you exceed a service limit. 
 
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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on April 18, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a left knee replacement. 
 
You asked the Plan to pre-approve a left knee replacement. 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 a left knee replacement. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found detailed documentation regarding a trial and failure of recent, reasonable, 
comprehensive, less invasive conservative care measures is not evident. She had a cortisone injection on May 
23, 2023 and is doing water therapy as of the August 1, 2023 progress report. However, there is no indication of a trial and failure of any viscosupplementation/Hyalgan injections. The documentation does not clearly 
document how long she has been in water therapy and/or any therapy notes to corroborate her lack of 
progression. There are limited large-scale, long-term references showing the safety and efficacy of the 
requested surgery in this clinical setting. No compelling rationale is presented, or extenuating circumstances 
noted to support the medical necessity of this request as an exception. Therefore, the requested left knee 
replacement is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a left knee replacement have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a left knee replacement.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pulpal debridement, primary and permanent teeth tooth #20 
(D3221) provided on April 5, 2023. 
 
You asked the Plan to pay for the pulpal debridement. You say that you went to the dentist for a root canal due 
to extreme pain. You also say that the dentist could only do half the procedure otherwise you would have had 
to wait 2-3 weeks to get in. The Plan denied your request. The Plan says if a code is not included in the list, that 
service is not a benefit of the plan. A pulpal debridement, procedure code D3221, is not included on the 
covered code list. 
 
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 pulpal 
debridement, primary and permanent teeth tooth #20 (D3221) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of a refractive state (92015) provided on 
April 3, 2023.  
You asked the Plan to pay for a determination of a refractive state (92015). You say that you feel you should 
not be responsible for the charge of the refraction. The Plan denied your request. The Plan says the member had 
a diagnostic eye examination on the date of service in question, not a routine eye exam. Your coverage does not 
provide for this 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 they are part of a routine eye examination. 
 
We looked at the file and the Plan's rules. The Plan rules also say that Original Medicare does not cover routine 
eye exams (eye refractions) for eyeglasses/contacts. Based on this information, we decided that the Plan's rules 
for coverage of a determination of a refractive state (92015) have not been met. Therefore, we decided that the 
Plan does not have to pay for a determination of a refractive state (92015) provided on April 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0220) provided on April 
12, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dentist performed the procedures without 
verifying it was a covered benefit. The Plan denied your request. The Plan says the denial of payment for these 
services is correct, because the intraoral radiographic images 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 
intraoral radiographic images (D0220) provided on April 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a leg massager purchased on January 2, 2023. 
 
You asked the Plan to reimburse for a leg massager. You say that you saw that massage services were not 
approvable when you looked at the wellness wallet lists of authorized expenses. You also say that since this 
purchase is a machine, you presumed it would be accepted. The Plan denied your request. The Plan says this is 
a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that the item or service must be primarily health 
related; that is, the primary purpose of the item or service is to prevent, cure or diminish an illness or injury. If 
the primary purpose of the item or service is comfort, cosmetic or daily maintenance, then it is not eligible as a 
supplemental benefit.  
 
We looked at the file, Plan rules and Medicare rules. The Plan rules say the Plan will reimburse members for 
certain services not covered by Original Medicare. The Plan will reimburse up to $300 each year in total for 
Fitness, Naturopathic Services, Acupuncture, Nutrition/Dietary Education, Weight Management Programs, and 
Face Masks. Leg massagers are excluded from this benefit. Based on this information, we decided that 
Medicare rules for coverage of a leg massager have not been met. Therefore, we decided that the Plan does not 
have to reimburse for a leg massager purchased on January 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each physical therapy (PT) visit provided 
on May 30, 2023. 
 
You asked the Plan to waive the copayment for each physical therapy (PT) visit. You say that you disagree 
with the additional $35 copayment that was applied. 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 outpatient rehabilitation services. 
 
You have been asked to pay a $35 copayment for each physical therapy (PT) visit. This item/service falls 
within the outpatient rehabilitation 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 each physical therapy (PT) visit provided on May 30, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for date of service March 26, 
2023 to April 22, 2023. 
 
You asked the Plan to pay for procedure code S9328. You say that the claim should be paid. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for date of service March 26, 2023 to April 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92012), a determination of 
refractive state (92015) and fundus photography (92250) provided on March 09, 2023. 
 
You asked the Plan to pay for a medical eye examination (92012), a determination of refractive state (92015) 
and fundus photography (92250). You say that the doctor was supposedly within the network for the study. 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 medical eye 
examination (92012), a determination of refractive state (92015) and fundus photography (92250) provided on 
March 09, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on February 28, 2023. 
 
You asked the Plan to pay for home visit. You say that you are appealing the claim payment denial. 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 home visit provided on 
February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) provided on 
March 28, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the crown 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 crown was exhausted on date of service January 26, 2021. Therefore, we decided 
that the Plan does not have to pay for a crown (D2740) and core buildup (D2950) provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided March 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had no idea you would be billed this much. 
The Plan denied your request. The Plan says your benefit for the requested item or service has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record shows your benefit for the requested item or service was exhausted on date of service February 7, 2023. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided March 
31, 2023.