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

 
We decided that the Plan does not have to pre-approve bone replacement grafts for teeth #6 and #29 (D7953). 
 
You asked the Plan to pre-approve 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 pre-approve bone 
replacement grafts for teeth #6 and #29 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7210) for tooth #10 and #11 and 
analgesia (D9239) and to pay for the guided tissue regeneration (D4266) for tooth #10, the surgical placement 
of implant body (D6010) for tooth #10 and #11, a bone graft (D6104) for tooth #10, and the collection and 
application of blood concentrate (D7921) provided by an out-of-network provider on July 18, 2023.  
You asked the Plan to pay more for the dental services. You say that after x-rays were taken it was medically 
necessary for the teeth to be extracted and replaced with implants. The Plan denied your request. The Plan says 
the enrollee is responsible for any charged amount above the Plans cost-sharing amount when your services 
are received from an out-of-network provider. Also, the guided tissue regeneration, the surgical placement of 
implant body, a bone graft, and the collection and application of blood concentrate 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. 
 
The total amount billed for the extraction (D7210) for tooth #10 was $375 and the total allowed amount was 
$145 leaving a difference of $230 ($375 billed - $145 allowed). The total amount billed for the extraction 
(D7210) for tooth #11 was $412 and the total amount allowed was $145 leaving a difference of $267 ($412 
billed - $145 allowed). The total amount billed for the analgesia (D9239) was $639 and the total allowed 
amount was $205 leaving a difference of $434 ($639 billed - $205 allowed). 
 
The enrollee has been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation the enrollee agreed to pay when you enrolled in the Plan. 
The guided tissue regeneration, the surgical placement of implant body, a bone graft, and the collection and 
application of blood concentrate are not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay more for an extraction (D7210) for tooth #10 and #11 and analgesia (D9239) and to 
pay for the guided tissue regeneration (D4266) for tooth #10, the surgical placement of implant body (D6010) 
for tooth #10 and #11, a bone graft (D6104) for tooth #10, and the collection and application of blood 
concentrate (D7921) provided by an out-of-network provider on July 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the porcelain/ceramic crown (D2740), core buildup, 
including pins when required (D2950), and the unspecified restorative procedure, by report (D2999) provided 
on August 22, 2023. 
 
You asked the Plan to pay more for the dental items/services. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the 
items/services provided in this case 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 items/services provided was exhausted on date of service August 22, 2023. 
Specifically, the Plans contract states that there is $1,500 combined allowance for supplemental preventive 
and comprehensive dental services every year. The Plan previously issued payments for the total amount of 
$1,500 ($344 + $1156) for dental items/services provided in the 2023 calendar year. Therefore, you have 
exhausted the allowable benefit for these items/services. Therefore, we decided that the Plan does not have to 
pay more for the porcelain/ceramic crown (D2740), core buildup, including pins when required (D2950), and 
the unspecified restorative procedure, by report (D2999) provided on August 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and 
surgical extraction (D7210) provided from July 21, 2023, to August 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that due to an infection your tooth had to be 
extracted. You consider this a preventive procedure and those are covered benefits. The Plan denied your 
request. The Plan says these services are not covered benefits 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 
problem focused limited oral evaluation (D0140) and surgical extraction (D7210) provided from July 21, 2023, 
to August 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2335 x 3) provided on June 23, 
2023. 
 
You asked the Plan to pay for the dental services. You say that your provider told you that you would not have 
to pay anything, and these services are covered benefits. 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 resin-
based composites (D2335 x 3) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5261, V5267) purchased 
on July 13, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at the case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from an out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5261, V5267) purchased on July 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on April 20, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the maintenance is important to your condition, 
and it is not the same as a cleaning. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the periodontal maintenance 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
periodontal maintenance (D4910) provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D3330, D0220) provided on August 15, 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.  
 
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 limited oral evaluation, intraoral x-ray, and 
endodontic therapy (D0140, D3330, D0220) provided on August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), bitewings (D0274), and a cleaning (D1110) provided by an out-of-network provider on September 7, 2023.

You asked the Plan to pay more for the dental services. You say that the provider told you that they were in-network. The Plan denied your request. The Plan says you are responsible for any charged amount above the Plan's cost-sharing amount when your services are received from an out-of-network provider. Also, it was verified with the provider's office that you were told that they do not accept any insurance and you would be responsible for the balance.

Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

The total amount billed for the comprehensive oral evaluation (D0150) was $75 and the total allowed amount was $42.72 leaving a difference of $32.28 ($75 billed - $42.72 allowed). The total amount billed for the bitewings (D0274) was $60 and the total allowed amount was $33.91 leaving a difference of $26.09 ($60 billed - $33.91 allowed). The total amount billed for the cleaning (D1110) was $95 and the total allowed amount was $50.52 leaving a difference of $44.48 ($95 billed - $50.52 allowed).

You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 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 comprehensive oral evaluation (D0150), bitewings (D0274), and a cleaning (D1110) provided by an out-of-network provider on September 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2740, D2950, D1110 and D1330) on 
July 31, 2023. 
 
You asked the Plan to pay for the dental services (D2740, D2950, D1110 and D1330). You say that you would 
like to request reconsideration for payment. 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 31, 2023. Therefore, we decided that the Plan does not have to pay for the dental services (D2740, D2950, D1110 and D1330) on 
July 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics.  
 
You asked the Plan to pay for foot orthotics. You say that you feel the boot should be covered under the 
durable medical equipment category. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
  Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental service (D9120) on July 17, 2023. 
 
You asked the Plan to pay for the dental service (D9120). You say that you would like to request 
reconsideration for payment. 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 the dental service (D9120) on July 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on July 5, 2023, to July 12, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on July 5, 2023, to 
July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
26, 2023. 
 
You asked the Plan to pay for the dental service. You say that you pay extra for extra coverage. 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 periodontal maintenance (D4910) on January 10, 2023, and May 16, 2023; therefore, 
your benefit for the requested item or service was exhausted on the date of service of May 16, 2023. Therefore, 
we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on September 
26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0272) provided on August 23, 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 June 6, 2023. Therefore, 
we decided that the Plan does not have to pay for bitewing x-rays (D0272) provided on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 19, 
2023. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied service because it 
should have been covered. The Plan denied your request. The Plan says your dental maximum benefit for the 
year 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 $607 for dental services on June 21. 2023. On June 28, 2023, the Plan paid $393 for dental 
services. For the year of 2023 the Plan paid $1,000 ($607 paid + $393 paid) for dental services; therefore, your 
dental maximum benefit for the year of 2023 was exhausted on the date of service of June 28, 2023. Therefore, 
we decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 19, 
2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a complete lower denture (D5120). 
 
You asked the Plan to pre-approve this dental item. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says that your benefit for the requested item has already 
been exhausted. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. Specifically, the Plan has not provided substantiative evidence that demonstrates your 
benefit for the requested item was previously exhausted. The Plan has not substantiated their denial; therefore, 
we must find in your favor. Therefore, we decided that the Plan has to pre-approve a complete lower denture 
(D5120).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image, surgical removal of erupted 
tooth and interim partial denture maxillary. 
 
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 panoramic radiographic image has already been exhausted. Surgical 
removal of erupted tooth and interim partial denture maxillary are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the panoramic radiographic image was exhausted on date of service June 7, 2022. Surgical removal of erupted tooth and interim partial denture maxillary are not covered services. Therefore, we 
decided that the Plan does not have to pay for panoramic radiographic image, surgical removal of erupted tooth 
and interim partial denture maxillary.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services with additional mileage received on 
September 19, 2023. 
 
You asked the Plan to pay for the ambulance services with additional mileage. You say that the services were 
medically necessary. The Plan denied your request. The Plan says you requested to be transported to a further 
away hospital which was not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that all services that are medically necessary are 
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ambulance services with additional mileage have not been met. Therefore, we decided that the 
Plan does not have to pay for the ambulance services with additional mileage received on September 19, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) visit (99284, 96372, J1885, J1100) 
provided on July 12, 2022. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) visit (99284, 
96372, J1885, J1100) provided on July 12, 2022.