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

 
We decided that the Plan does not have to pay for bitewings - four radiographic images (D0274), and periodic 
oral evaluation - established patient (D0120) provided on January 6, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D0274 and D0120. You say that 
coverage is calendar year and maximum was not met at this time. The Plan denied your request. The Plan says 
your benefit for the requested services $1,000 dollar limit was met. 
 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 March 23, 2022. The Health 
Plan processes claims in the order in which the claims are received. The claims for dates of service March 2, 
2022, March 10, 2022 and March 23, 2022 had been paid on March 16, 2022, March 29, 2022 and April 29, 
2022 respectively. When the Plan received your claim for reimbursement for January 6, 2022 date of service on 
May 22, 2022, the enrollee had already utilized the maximum plan benefit for non-Medicare covered dental 
services of $1000. Therefore, we decided that the Plan does not have to pay for bitewings - four radiographic 
images (D0274), and periodic oral evaluation - established patient (D0120) provided on January 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
August 10, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acupuncture services in this case were not 
rendered on the basis of a covered diagnosis.  
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) provided on August 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811) provided on 
October 14, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acupuncture services in this case were not 
rendered on the basis of a covered diagnosis.  
 
 
 
  
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the acupuncture services in this case were not 
rendered on the basis of a diagnosis for chronic low back pain. Therefore, we decided that the Plan does not 
have to pay for the acupuncture treatments (97810, 97811) provided on October 14, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 sensor. 
 
You asked the Plan to pre-approve the Dexcom G7 sensor. You say that the enrollee needs the Dexcom to help 
with their diabetes. The Plan denied your request. The Plan says only the preferred brand products listed in the 
EOC are covered.  
  The Plan must follow Medicare rules. Medicare rules say that plans may specify brands and manufacturers as 
preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred 
brands and manufacturers. Plans must ensure that enrollees have access to all medically necessary (including 
non- preferred) DME products or brands. The rules also say that a health plan must disclose to its enrollees, in 
clear accurate terms, the benefits offered under a plan, including applicable conditions and limitations 
associated with receipt or use of benefits. 
 
We looked at the file and Medicare rules. According to the EOC, the requested brand is not a preferred brand 
for a glucometer and related supplies. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 sensor.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services received on December 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that these services were covered before. 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 services received on December 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation (D0120), bitewings (D0274), 
and a cleaning (D1110) and to pay for the intraoral radiographic images (D0220 and D0230) provided by and 
out-of-network provider on January 19, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know the provider was an out-
of-network provider. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. Also, 
the denial of payment for the intraoral radiographic images is correct because they 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. 
 You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment for periodic oral evaluation, bitewings, and a cleaning. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. The intraoral radiographic images are not covered under the 
Plans dental benefit. Therefore, we decided that the Plan does not have to pay more for a periodic oral 
evaluation (D0120), bitewings (D0274), and a cleaning (D1110) and to pay for the intraoral radiographic 
images (D0220 and D0230) provided by and out-of-network provider on January 19, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapeutic exercises (97110), manual therapy (97140), and 
electrical stimulation (G0283) provided on August 29, 2022, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for therapeutic exercises, manual therapy, and electrical stimulation. You say that 
you want the Plan to reconsider payment for these services. The Plan denied your request. The Plan says no 
medical necessity for an out-of-network provider, such as an urgent or emergency situation, has been 
documented. 
 
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 therapeutic exercises (97110), manual therapy 
(97140), and electrical stimulation (G0283) provided on August 29, 2022, by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D5120 and D5110). 
 
You asked the Plan to pre-approve the dental services (D5120 and D5110). You say that you would like to 
request reconsideration of the denied authorization. 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 service were exhausted on date of service July 01, 2019 (D5110), and 
March 03, 2022 (D5120). Therefore, we decided that the Plan does not have to pre-approve the dental services 
(D5120 and D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyeglasses purchased on January 12, 2023, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the eyeglasses. You say that you went to the OON provider because they have 
excellent prices and customer service, and gave you a quote of $229.98 for exactly what you wanted. You also 
say that you are not asking for anything more than the amount of the glasses from your benefit, and the Plan 
will be saving $70.00. The Plan denied your request. The Plan says the provider that performed these services 
is not in the Plan's network. 
 
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 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 the eyeglasses purchased on January 12, 2023, by 
an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0367), an immediate upper denture (D5130), 
an immediate lower denture (D5140), the surgical placement of implant body (D6010), bone replacement grafts 
(D6104), abutments (D6191 and D6192), and bone replacement grafts (D7953) for tooth #7, #12, #20, #22, 
#25, and #28 provided on December 28, 2022. You asked the Plan to pay for the dental services. You say that you thought you had the same coverage for 
2022 as you did 2023 or else you would have not gotten the dental procedures done. The Plan denied your 
request. The Plan says the denial of payment for these services is correct, because the cone beam, dentures, the 
surgical placement of implant body, bone replacement grafts, abutments, and bone replacement grafts 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 a cone 
beam (D0367), an immediate upper denture (D5130), an immediate lower denture (D5140), the surgical 
placement of implant body (D6010), bone replacement grafts (D6104), abutments (D6191 and D6192), and 
bone replacement grafts (D7953) for tooth #7, #12, #20, #22, #25, and #28 provided on December 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the deluxe frames (V2025) and progressive lenses (V2781) 
provided on December 6, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the eyewear. You say that you understand that the Plan does not cover eyewear 
from a non-participating supplier, but the benefit was sold to you as a $150.00 claim. You also say that it 
should be paid to you directly to purchase glasses. The Plan denied your request. The Plan says OON vision 
services are not covered by the Plan. 
 
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 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 the deluxe frames (V2025) and progressive lenses 
(V2781) provided on December 6, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dermatology appointment provided on November 16, 2021. 
 
You asked the Plan to pay for a dermatology appointment. You say that this was medically necessary and 
should be covered. 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 dermatology 
appointment provided on November 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an exam (D0140), pulp test (D0460), root canal obstruction 
(D3331) and intraorifice barrier (D3911) provided on December 13,2022. 
 
You asked the Plan to pay for an exam, pulp test, root canal obstruction and intraorifice barrier. 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 an exam 
(D0140), pulp test (D0460), root canal obstruction (D3331) and intraorifice barrier (D3911) provided on 
December 13,2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the x-ray provided on March 07, 2023. 
 
You asked the Plan to reduce the copayment for the x-ray. You say that the x-ray was performed in the 
providers office. 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 $110 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $110 copayment for the x-ray. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and 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. The record shows you received services from an outpatient hospital. However, since the allowed amount is less than the standard copayment, you only owe $82.07. 
Therefore, we decided that the Plan does not have to reduce the copayment for the x-ray provided on March 07, 
2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a radiological examination of the shoulder (73030) provided 
on December 20, 2022, by an out-of-network (OON) provider.  
   
You asked the Plan to pay for a radiological examination of the shoulder. You say that the service was 
medically necessary. The Plan denied your request. The Plan says the services were not urgent or emergent and 
the services could have been rendered by a participating  
provider. 
 
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 radiological examination of the shoulder (73030) 
provided on December 20, 2022, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary or rest home visit for the evaluation and 
management of an established patient (99335) provided on December 5, 2022, by an out-of-network (OON) 
provider.  
 You asked the Plan to pay for domiciliary or rest home visit for the evaluation and management of an 
established patient. You say that the facility is responsible to obtain prior authorization. The Plan denied your 
request. The Plan says the services were not urgent or emergent and the services could have been rendered by a 
participating provider. 
 
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 domiciliary or rest home visit for the evaluation 
and management of an established patient (99335) provided on December 5, 2022, by an out-of-network 
(OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the eyeglasses (V2020, V2100) purchased on 
December 12, 2022.  
You asked the Plan to reimburse you for the eyeglasses. You say that you want the Plan to reimburse you for 
the eyeglasses. The Plan denied your request. The Plan says the payment does not meet criteria for approval 
due to the services were provided by an out-of-network provider without prior authorization. 
 
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 with an out-of-network provider only with prior authorization. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the eyeglasses have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the eyeglasses (V2020, V2100) purchased on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on November 22, 2022. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you were under the 
impression that you would be reimbursed for the service. You also say that you were told to pay now, and the 
office would send it to your insurance company. The Plan denied your request. The Plan says if you receive a 
service not listed in the table, you will have to pay the full cost. 
 
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 a limited oral 
evaluation - problem focused (D0140) provided on November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aids (V5298) purchased on January 5, 2023 from 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the hearing aids. You say that you knew that the provider you purchased these 
hearing aids from was OON, but their cost was much less than going through an in-network doctor. You also 
say that you would like to be reimbursed some, if not all, of the cost for these hearing aids. The Plan denied 
your request. The Plan says there is no coverage for hearing aids when received from a non-Plan approved 
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 you use a Plan approved hearing aid vendor. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for 
the hearing aids (V5298) purchased on January 5, 2023 from an out-of-network (OON) provider.