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

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), and prophylaxis - adult (D1110) provided on March 30, 2023. 
 
You asked the Plan to pay more for the periodic oral evaluation and prophylaxis - adult. You say that you were 
advised after you called the plan that the provider was and an in-network provider. You also say that you are 
appealing as the claim is not processing 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 a periodic oral evaluation - established 
patient (D0120), and prophylaxis - adult (D1110) provided on March 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for contact lenses (V2599) provided on March 2, 2023.  
You asked the Plan to pay for contact lenses (V2599). You say that you were billed $392 by the provider for 
this same claimed service, not $250 as was stated on the claim. You also say you paid $142 out of pocket, not 
$0 as stated on the claim record. The Plan denied your request. The Plan says the enrollee has already utilized 
the full benefit amount. 
 
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 up to $250 every year for non-Medicare covered prescription eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that they pay up to $250 every year for non-
Medicare covered prescription eyewear. The Plan rules also say you are responsible for any amount above the 
eyewear coverage limit. Based on this information, we decided that the Plan's rules for coverage of contact 
lenses (V2599) have not been met. Therefore, we decided that the Plan does not have to pay for contact lenses 
(V2599) provided on March 2, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home health visit provided on July 10, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the home health visit. You say that the services provided were a medical 
necessity. The Plan denied your request. The Plan says the out-of-network services were not authorized. 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a home health visit provided on July 10, 2022, by 
an out-of-network (OON) provider.
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 December 14, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that your 
daughter who is a registered nurse came to examine you. You also say that your daughter took responsibility of 
you and felt you were okay. 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 December 14, 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 December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788) 
provided on March 22, 2023. 
 
You asked the Plan to pay for presbyopia correcting function of intraocular lens (V2788). You say that you 
were advised that for medical reasons, the single focus lens which would have been completely covered was 
not suitable for the enrollee. The Plan denied your request. The Plan says this is not a covered benefit. 
 
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 standard frames and lenses as defined by Medicare after cataract surgery. 
 
We looked at the file and the Plan's rules. The Plan rules say they cover one pair of eyeglasses or contact lenses 
after each cataract surgery that includes insertion of an intraocular lens. The Plan rules also say that covered 
eyeglasses after cataract surgery includes standard frames and lenses as defined by Medicare. The Plan rules 
also say any upgrades are not covered. Based on this information, we decided that the Plan's rules for coverage 
of presbyopia correcting function of intraocular lens (V2788) have not been met. Therefore, we decided that 
the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788) provided on March 
22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided on March 
8, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image. You say that this should be covered as you 
have not had this before. The Plan denied your request. The Plan says your benefit for panoramic radiographic 
image 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 panoramic radiographic image was exhausted on date of service November 7, 2022. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image (D0330) provided 
on March 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral - complete series of radiographic images 
(D0210), panoramic radiographic image (D0330), comprehensive oral evaluation - new or established patient 
(D0150), periodontal maintenance (D4910), and extraction, erupted tooth requiring removal of bone and/or 
sectioning of tooth (D7210) provided on March 22, 2023, and April 5, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D0210, D0330, D0150, D4910 and 
D7210. You say that you were not informed that you had to go to certain dentists.  You also say that you were under the impression that if they took your card and scheduled your appointment 
they were contracted with the plan. 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 an intraoral - complete series of radiographic images (D0210), panoramic radiographic image 
(D0330), comprehensive oral evaluation - new or established patient (D0150), periodontal maintenance 
(D4910), and extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided 
on March 22, 2023, and April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a determination of refractive state (92015) provided on 
February 22, 2023.  
You asked the Plan to pay for a determination of refractive state (92015). You say that you were unaware the 
service performed was not covered. The Plan denied your request. The Plan says refractive services are not 
covered under your medical benefit plan. 
 
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 performed as part of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that original Medicare does not cover routine eye 
exams (eye refractions) for eyeglasses/contacts. The record shows this was a medical/diagnostic eye 
examination. Based on this information, we decided that the Plan's rules for coverage of a determination of 
refractive state (92015) have not been met. Therefore, we decided that the Plan does not have to pay for a 
determination of refractive state (92015) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral examination (D0140) provided on January 25, 
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 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 November 14, 2022. 
Therefore, we decided that the Plan does not have to pay for limited oral examination (D0140) provided on 
January 25, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diabetic supplies provided on March 
19, 2023. 
 
You asked the Plan to waive the copayment for the diabetic supplies. You say that you should not be 
responsible for the coinsurance for the items you were billed for because in 2022 you did not have a 
copayment. 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 $0 in-
network copayment for preferred Medicare-covered diabetic services and supplies when obtained through a 
network pharmacy. It also says the enrollee must pay 20% in-network coinsurance for Medicare-covered 
durable medical equipment.  
 
You have been asked to pay a $51, which is 20% of the allowed amount for the diabetic supplies. The allowed 
amount is $255.01 (20% x $255.01 = $51). Based on the information received, the pharmacy is out-of-network, 
therefore, you were billed the 20% coinsurance. This item/service falls within the durable medical equipment 
(DME) and related supplies benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the diabetic 
supplies provided on March 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass lens, tint for eyeglass lens, 
and anti-reflective lens coating provided on December 29, 2022. 
 
You asked the Plan to pay for eyeglass frames, trifocal eyeglass lens, tint for eyeglass lens, and anti-reflective 
lens coating. You say that you were told that you needed to pay and would get reimbursed by the Plan. You 
also say you have no extra money. The Plan denied your request. The Plan says the optical frame allowance has 
been exhausted. 
 
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 $250 allowance every calendar year that you can use to pay for eyewear to correct 
vision. 
 
We looked at the file and the Plan's rules. The Plan rules say that the Plan provides a $250 allowance every 
calendar year for Plan vision members that you can use to pay for eyewear to correct vision. The record shows 
this benefit was exhausted with this service. Based on this information, we decided that the Plan's rules for 
coverage of eyeglass frames, trifocal eyeglass lens, tint for eyeglass lens, and anti-reflective lens coating have 
not been met. Therefore, we decided that the Plan does not have to pay for eyeglass frames, trifocal eyeglass 
lens, tint for eyeglass lens, and anti-reflective lens coating provided on December 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings  (D0274) and a comprehensive oral evaluation 
(D0150) provided on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that the provider did not say that they do not take 
this 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 bitewings  (D0274) and a comprehensive oral evaluation (D0150) provided on February 8, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, advanced life support and ground 
mileage provided on January 5, 2022. 
 
You asked the Plan to pay for the ambulance transport service and ground mileage . You say that you are 
asking for special consideration as the patient was not communicating and the provider was shorthanded during 
this period of time. The Plan denied your request. The Plan says the claim was untimely, and the submission 
did not meet the exception criteria guidelines outlined in 42 CFR Section 424.44. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the ambulance transport service and ground mileage  was not filed until 
March 3, 2023. This means that more than one calendar year from the date of service had passed before a claim 
was filed. Therefore, we decided that the Plan does not have to pay for ambulance service, advanced life 
support and ground mileage provided on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an intraorifice barrier (D3911), and cone beam CT 
capture and interpretation with limited field of view  less than one whole jaw (D0364) provided on February 
15, 2023. 
 
You asked the Plan to pay more for the intraorifice barrier and cone beam CT capture. You say that you were 
told that the enrollee had not used any of their benefits and there was $2,000.00 remaining. You also say that 
you were not told that there was a pending claim. The Plan denied your request. The Plan says your benefit for 
the requested services $2,000 dollar limit was met. Since your annual maximum has been satisfied by these 
claims, no additional payment will be made. 
 
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 services was exhausted on dates of February 15, 2023. Therefore, we 
decided that the Plan does not have to pay more for an intraorifice barrier (D3911), and cone beam CT capture 
and interpretation with limited field of view  less than one whole jaw (D0364) provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anti-reflective coating (V2750) provided on January 18, 
2023.  
You asked the Plan to pay for anti-reflective coating (V2750). You say that you are appealing with supporting 
records. The Plan denied your request. The Plan says we only cover Medicare-covered basic frames and a 
basic/standard contact lens. 
 
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 only covers Medicare-covered basic frames and lenses are covered. 
 
We looked at the file and the Plan's rules. The Plan rules say that only Medicare-covered basic frames and 
lenses are covered. Based on this information, we decided that the Plan's rules for coverage of anti-reflective 
coating (V2750) have not been met. Therefore, we decided that the Plan does not have to pay for anti-reflective 
coating (V2750) provided on January 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for magnetic resonance imaging (MRI), brain with contrast 
provided on April 22, 2022. 
 
You asked the Plan to pay for magnetic resonance imaging (MRI), brain with contrast. 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 magnetic resonance 
imaging (MRI), brain with contrast provided on April 22, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on January 03, 2023, to January 
20, 2023. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on January 03, 2023, to January 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for frames (V2020), bifocal lenses (V2204 and V2203) 
and polycarbonate lens (V2784) purchased on March 15, 2023. 
 
You asked the Plan to pay more for frames (V2020), bifocal lenses (V2204 and V2203) and polycarbonate lens 
(V2784). You say that any discount the provider gives should benefit the customer and not the insurance 
company. 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 has a $100 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 say that members have a $100 benefit toward the 
purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). Based on this 
information, we decided that the Plan's rules for coverage of frames (V2020), bifocal lenses (V2204 and 
V2203) and polycarbonate lens (V2784) have not been met. Therefore, we decided that the Plan does not have 
to pay more for frames (V2020), bifocal lenses (V2204 and V2203) and polycarbonate lens (V2784) purchased 
on March 15, 2023.