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

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and a complete lower 
denture (D5120). 
 
You asked the Plan to pre-approve the dental services. You say that your doctor recommended a complete set 
of dentures and your policy shows that they are covered. The Plan denied your request. The Plan says the 
denial of authorization for these services is correct, because dentures 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 pre-approve a 
complete upper denture (D5110) and a complete lower denture (D5120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided December 1, 
2022. 
 
You asked the Plan to pay for the dental services. You say that the first dentist was not able to fix your tooth. 
You were forced to go to a dentist you have used in the past, recently in another exam. 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 October 4, 2022. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided 
December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on March 01, 2023. 
 
You asked the Plan to pay for a home visit. You say that you are requesting reconsideration of the denied 
claim. 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 home visit provided on 
March 01, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit provided on February 10, 2023. 
 
You asked the Plan to pay for a home visit. You say that the facility is responsible for authorization for all of 
their patients. 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 home visit provided on 
February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete denture - maxillary (D5110), complete 
denture - mandibular (D5120), and extractions, erupted tooth or exposed root (elevation and/or forceps 
removal) (D7140).  
 
You asked the Plan to pre-approve the dentures and extractions. You say that you have broken teeth that keep 
getting into your system and you have no energy. The Plan denied your request. The Plan says dental services 
from an out-of-network provider 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.  
You are requesting 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 pre-approve a complete 
denture - maxillary (D5110), complete denture - mandibular (D5120), and extractions, erupted tooth or exposed 
root (elevation and/or forceps removal) (D7140).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown on existing implant (D6066) provided on May 2, 
2023. 
 
You asked the Plan to pay for crown on existing implant. 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 crown on 
existing implant (D6066) provided on May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an abutment supported porcelain fused to metal crown (high 
noble metal) (D6059), and custom fabricated abutment  includes placement (D6057) provided on April 11, 
2023. 
 
You asked the Plan to pay for the dental services. You say that based on coverage the Plan is responsible for 
50%. The Plan denied your request. The Plan says dental services D6059 and D6057 are not covered by your 
benefit plan in 2023. 
 
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 
abutment supported porcelain fused to metal crown (high noble metal) (D6059), and custom fabricated 
abutment  includes placement (D6057) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on March 16, 2023. 
 
You asked the Plan to pay for dental services. 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 after $100 deductible for Class 2 Basic Services. The Plan contract also says that if the Plan 
determines that (1) a less expensive procedure, service, or course of treatment can be performed in place of your dentists proposed treatment and (2) the less expensive alternative will produce a professionally 
satisfactory result, then the maximum allowed by the Plan will be the charge for the less expensive alternative. 
 
You have been asked to pay $221.50 for the dental services. This item/service falls within the 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 pay for dental services provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110/D5120). 
 
You asked the Plan to pre-approve the dental services. You say that you are in a lot of pain and cannot eat. 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 August 1, 2019. Therefore, we decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture 
(D5110/D5120).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient visit provided on January 09, 2023, by an out-of-
network (OON) provider.  
 
 You asked the Plan to pay for outpatient visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 of Chapter 3). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of the plans network) will not be 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 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 outpatient visit provided on January 09, 2023, 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 July 29, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you were 
already at the hospital when an ambulance was called. You also say that you never requested one and was 
never in a state where you needed one since you were at the hospital already.  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 July 29, 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 July 29, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on April 26, 
2023. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you say that you already paid 
the 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 $200 
copayment for outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory 
surgical centers. 
 
You have been asked to pay a $200 copayment for outpatient surgery. This item/service falls within the outpatient surgery, including services provided at hospitaloutpatient facilities and ambulatory surgical centers 
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 outpatient surgery provided on 
April 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network right shoulder x-ray provided 
on March 9, 2022. You were asked to pay $88 towards this deductible. 
 
You asked the Plan to waive the deductible for an in-network right shoulder x-ray. You say that you had met 
your deductible in April of that year. The Plan denied your request. The Plan says this $88 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 $680 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 
The item or service you asked the Plan to waive the deductible for falls within the outpatient diagnostic tests 
and therapeutic services and supplies benefit category. The Plan has followed Medicare rules by clearly 
disclosing in the contract that there is a $680 deductible which applies to outpatient diagnostic tests and 
therapeutic services and supplies.  
 This cost sharing is a contractual obligation that had not been met at the time an in-network right shoulder x-
ray was received on March 9, 2022. Therefore, we decided that the Plan does not have to waive the deductible 
for an in-network right shoulder x-ray provided on March 9, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound provided on March 23, 2023. 
 
You asked the Plan to pay for ultrasound. You say that you are requesting reconsideration for the services 
provided. 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 ultrasound provided on 
March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on October 12, 2022. 
 
You asked the Plan to pay for the office visit. You say that you are requesting reconsideration of the denied 
claim. 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 the office visit provided 
on October 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an international normalized ratio (INR) monitoring services 
provided on May 15, 2023. 
 
You asked the Plan to pay for an international normalized ratio (INR) monitoring services. 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 an international 
normalized ratio (INR) monitoring services provided on May 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for office visit provided on April 10, 2023. 
 
You asked the Plan to waive the copayment for office visit. You say that you say that you never heard of this 
provider on the claim before. 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 $40 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $40 copayment for office visit. This item/service falls within the 
physician/practitioner services, including doctors office visits 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 office visit provided on April 10, 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 
March 31, 2023. We have also decided that the Plan does not have to waive the copayment for a specialist 
office visit. 
 
You asked the Plan to pay for a determination of refractive state (92015) You also asked the Plan to waive the 
copayment for a specialist office visit. You say that you do not understand why you were charged a copayment. 
The Plan denied your request. The Plan says you were charged a $35 copay for a specialist office visit, which is 
what is reflected in your EOC. The Plan also says that the refraction (92015) did deny as this is a Medicare 
non-covered code. 
 
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 determination of refractive state when they are apart of a routine examination. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $35 copayment for a specialist 
office visit. A specialist office visit falls under the Medicare-covered specialty care visit benefit category. The 
Plan rules also say that Original Medicare does not cover routine eye examinations (eye refractions) for 
eyeglasses/contacts. The record shows that you received a medical eye examination. Based on this information, 
we decided that the Plan's rules for coverage of a determination of refractive state (92015) and a specialist 
office visit have not been met. Therefore, we decided that the Plan does not have to pay for a determination of 
refractive state (92015) provided on March 31, 2023. We have also decided that the Plan does not have to 
waive the copayment for a specialist office visit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of benign nonodontogenic cyst or tumor - 
lesion diameter up to 1.25 cm (D7460). 
 
You asked the Plan to pre-approve the removal of benign nonodontogenic cyst or tumor. You say that you have 
an odontogenic cyst in your upper right cheek. You also say you have someone to do the surgery but they don't 
take your insurance. The Plan denied your request. The Plan says this type of oral surgery procedure is not 
covered under the benefit package. 
 
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 
removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7460).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of reaction producing foreign bodies (D7540), 
guided tissue regeneration (D4266), cone beam CT (D0365), and a bone graft (D6104). 
 
You asked the Plan to pre-approve 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 pre-approve 
removal of reaction producing foreign bodies (D7540), guided tissue regeneration (D4266), cone beam CT 
(D0365), and a bone graft (D6104).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for teeth cleaning provided on April 20, 2023. 
 
You asked the Plan to waive the copayment for teeth cleaning. 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 
copayment per visit for Medicare-covered dental services.  
 
You have been asked to pay $50 copayment for teeth cleaning. This item/service falls within the 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 copayment for teeth cleaning provided on April 
20, 2023.