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

 
We decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on March 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that what needed to be done was done. 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 July 14, 2021. Therefore, 
we decided that the Plan does not have to pay for panoramic radiographic imaging (D0330) provided on March 
22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950 x 3), pontic (D6245 x 3), and retainer 
crowns (D6740 x 3) provided on March 22, 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. Therefore, we decided that the Plan does not have to pay for core buildup (D2950 x 3), pontic (D6245 x 3), and retainer crowns (D6740 x 3) provided on 
March 22, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office (99214) provided on November 23, 2022. 
 
You asked the Plan to pay for a specialist office (99214). You say that you are appealing with supporting 
records. 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 specialist office 
(99214) provided on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite  two surfaces, posterior (D2392), a 
crown  porcelain/ceramic (D2740) and core buildup, including any pins when required (D2950) provided on 
February 20, 2023. 
 
You asked the Plan to pay for these dental services. 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 resin-based composite  two surfaces, posterior (D2392), a crown  porcelain/ceramic (D2740) and core buildup, 
including any pins when required (D2950) provided on February 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal guard (D9944) provided June 13, 2023. 
 
You asked the Plan to pay for an occlusal guard. You say that you were grinding your teeth. The Plan denied 
your request. The Plan says this 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 an 
occlusal guard (D9944) provided June 13, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Comprehensive PGX hereditary pharmacogenomic 
testing and the Comprehensive Cardio hereditary genetic testing provided on January 30, 2023.  
 
You asked the Plan to pay for the Comprehensive PGX hereditary pharmacogenomic testing and the 
Comprehensive Cardio hereditary genetic testing. You say that this testing was medically necessary for the 
determination of whether medicines this enrollee is taking are beneficial or could increase risk toward an 
adverse drug reaction because the enrollee is taking several medications. The Plan denied your request. The 
Plan says the enrollee does not meet criteria for coverage. 
 
The Plan follows Medicare rules. Medicare rules say that this testing is covered when the criteria in the rules 
section of this letter are met. 
 
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 pay for the Comprehensive PGX hereditary 
pharmacogenomic testing and the Comprehensive Cardio hereditary genetic testing. Our reviewer says that this 
testing was not medically reasonable and necessary. Our physician reviewer found that the documentation does 
not support that comprehensive PGX hereditary pharmacogenomic testing and the Comprehensive Cardio 
hereditary genetic testing provided on January 30, 2023, were medically necessary or met the criteria outlined. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the Comprehensive PGX hereditary pharmacogenomic testing and the 
Comprehensive Cardio hereditary genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the Comprehensive PGX hereditary pharmacogenomic testing and the Comprehensive 
Cardio hereditary genetic testing provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on April 14, 2023. 
 
You asked the Plan to pay for the prophylaxis - adult and periodic oral evaluation. The Plan denied your 
request. The Plan says your benefit for the requested 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 your benefit for the requested services was exhausted on date of service December 12, 2022. Therefore, 
we decided that the Plan does not have to pay for a prophylaxis - adult (D1110), and periodic oral evaluation - 
established patient (D0120) provided on April 14, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee would like to get back to being mobile 
and can do this with therapy to help them build up their strength. The Plan denied your request. The Plan says 
the enrollee does not meet the criteria for admission to an IRF. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a medical eye examination provided on 
March 13, 2023. 
 
You asked the Plan to waive the deductible for a medical eye examination. You say that this visit was for an 
eye infection. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to a medical eye examination.  
 
The item or service you asked the Plan to waive the deductible for falls within the Medicare-covered 
examination after your deductible is met benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is $400 deductible which applies to medical eye examinations. This cost 
sharing is a contractual obligation that had not been met at the time a medical eye examination was received on 
March 13, 2023. Therefore, we decided that the Plan does not have to waive the deductible for a medical eye 
examination provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a prophylaxis - adult (D1110), intraoral - periapical first 
radiographic image (D0220), each additional radiographic image (D0230), and bitewings - four radiographic 
images (D0274) provided on January 19, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D1110, D0220, D0230 and D0274. You 
say that you have been going to this dentist for years. You also say that this is the first time using this dental 
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 a prophylaxis - adult (D1110), intraoral - periapical first radiographic image (D0220), each 
additional radiographic image (D0230), and bitewings - four radiographic images (D0274) provided on January 
19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on May 23, 2023. 
 
You asked the Plan to pay for the office visit. You say that you did not know that the visit would not be 
covered. You say that you used to see this provider in the past with no issues of coverage. The Plan denied your 
request. The Plan says that an office visit is not a covered benefit when billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic serv 
 
ice Medicare covers is manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - one surface, posterior (D2391) 
provided on June 1, 2023. 
 
You asked the Plan to pay for the resin-based composite. The Plan denied your request. The Plan says this 
service is not covered 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for resin-based 
composite - one surface, posterior (D2391) provided on June 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a Prolia injection provided on August 23, 
2022. 
 
You asked the Plan to waive the coinsurance for a Prolia injection. You say that you feel you are not liable for 
the cost share 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 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for a Prolia injection. This item/service falls within the Medicare 
Part B Prescription Drugs benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $280.41, which is less than 20% of the allowed amount for the 
Medicare Part B covered drug, Prolia ($1,448.32 allowed x 20% = $289.66). Therefore, we decided that the 
Plan does not have to waive the coinsurance for a Prolia injection provided on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for  removal of erupted tooth (D7210) and 
biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on February 17, 2023. 
 
You asked the Plan to waive the coinsurance for  removal of erupted tooth and biologic materials. You say that 
this should be covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% 
coinsurance for extractions. Biologic materials are not a covered benefit. 
 
You have been asked to pay 50% coinsurance for removal of erupted tooth. This item/service falls within the 
Basic dental 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 coinsurance for  removal of erupted 
tooth (D7210) and biologic materials to aid in soft and osseous tissue regeneration (D4265) provided on 
February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for scleral, gas permeable contact lenses (V2531) and a 
prescription of contact lenses (92314) provided from January 26, 2023, to May 17, 2023. 
 
You asked the Plan to pay for scleral, gas permeable contact lenses (V2531) and a prescription of contact 
lenses (92314). You say that since wearing these lenses, you can see better which you are very thankful. You 
also say that your dry eyes are lubricated from the time you put the lenses in until you take them out. The Plan 
denied your request. The Plan says these are non-covered services. 
 
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 does not cover these services. 
 
We looked at the file and the Plan's rules. The Plan rules also say that eyeglasses for members with routine 
vision correction needs are covered by the Plan. Scleral, gas permeable contact lenses and a prescription of 
contact lenses are excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of scleral, gas permeable contact lenses (V2531) and a prescription of contact lenses (92314) have not 
been met. Therefore, we decided that the Plan does not have to pay for scleral, gas permeable contact lenses 
(V2531) and a prescription of contact lenses (92314) provided from January 26, 2023, to May 17, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each computed tomography (CT) scan 
provided on April 05, 2023, to April 13, 2023. 
 
You asked the Plan to waive the copayment for each computed tomography (CT) scan. You say that you only 
completed one of the three scans and should not be charged for a second scan. 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 $150 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $150 copayment for each 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 $300 for CT scans ($150 per scan x 2 scans = $300). 
Therefore, we decided that the Plan does not have to waive the copayment for each computed tomography (CT) 
scan provided on April 05, 2023, to April 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown and inhalation of nitrous oxide provided on 
April 10, 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 charges. The Plan denied your request. The Plan says your benefit for the crowns has already 
been exhausted on the appealed claim. Coverage for the inhalation of nitrous oxide 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, certain limitations apply. Coverage for 
the inhalation of nitrous oxide denied correctly as they do not fall within your dental benefits. Additionally, the 
record shows your benefit for the crowns exhausted on date of service April 10, 2023. Therefore, we decided 
that the Plan does not have to pay more for a crown and inhalation of nitrous oxide provided on April 10, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve urological supplies to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve the OON urological supplies. You say that the patient wants to use a local 
provider in the event of a hurricane or tropical storm. The Plan denied your request. The Plan says urological 
supplies are available from in-network providers. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
urological supplies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional intraoral x-ray (D0230) provided on April 26, 
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 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 April 26, 2023, on the 
appealed claim. Therefore, we decided that the Plan does not have to pay for an additional intraoral x-ray 
(D0230) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental service. You say that you are having a problem eating and you do 
not want implants, so you need a partial denture. 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 partial lower denture (D5214) on July 8, 2019; therefore, your benefit for the 
requested item or service was exhausted on the date of service of July 08, 2019. Therefore, we decided that the 
Plan does not have to pre-approve a partial lower denture (D5214).