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

 
We decided that the Plan does not have to pay more for the re-cement of a fixed partial denture (D6930), and 
prophylaxis (D1110), provided March 9, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this is a participating 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.  
 
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 the re-cement of a fixed partial denture 
(D6930), and prophylaxis (D1110), provided March 9, 2023.
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 March 31, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the advice 
nurse insisted on calling 911 to check your health. You also say that since you did not call 911 you should not 
be responsible for the payment. 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 March 31, 2023. 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 March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for unspecified adjunctive procedure (D9999), free soft tissue 
graft procedure (D4277 x2) and free soft tissue graft procedure (including donor site surgery) (D4278 x 2) 
provided on November 14, 2022, to December 23, 2022. 
 
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 
unspecified adjunctive procedure (D9999), free soft tissue graft procedure (D4277 x2) and free soft tissue graft procedure (including donor site surgery) (D4278 x 2) provided on November 14, 2022, to December 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110)  provided on December 22, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis - adult. You say that you feel the 
Plan should pay for the services.  The Plan denied your request. The Plan says your benefit for the periodic oral 
evaluation and prophylaxis - adult 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 periodic oral evaluation and prophylaxis - adult was exhausted on dates of service 
January 31, 2022, and June 20, 2022. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation - established patient (D0120), and prophylaxis - adult (D1110)  provided on December 22, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on May 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service January 17, 2023. 
Therefore, we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on 
May 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite - four or more surfaces (D2335) 
provided on February 21, 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 resin-based composite - four or more surfaces (D2335) provided on February 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a miscellaneous vision item or service (V2799) provided on 
December 6, 2022.  
 
You asked the Plan to pay for a miscellaneous vision item or service (V2799). You say that the lens options 
were purchased per your doctors recommendations. The Plan denied your request. The Plan says you are 
responsible for any amount over the $100 retail price. 
 
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 $100 towards the purchase and fitting of eyeglasses and pair of lenses. 
 
We looked at the file and the Plan's rules. The Plan rules say that you have a choice of a $100 benefit toward 
the purchase and fitting of eyeglasses and pair of lenses or contact lenses (1 per calendar year). The Plan rules 
also say that you pay any amount over the $100 retail price. The record shows that the submitted charge is 
$675. After deducting the $100 according to your EOC, and the 20% discount you were given, you were left 
with a responsibility of $460 ($675 - $100 = $575) ($575 x 20% = $460). The record also therefore shows that 
this benefit has been exhausted on December 6, 2022. Based on this information, we decided that the Plan's 
rules for coverage of a miscellaneous vision item or service (V2799) have not been met. Therefore, we decided 
that the Plan does not have to pay for a miscellaneous vision item or service (V2799) provided on December 6, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for polycarbonate lenses (V2784), progressive lenses (V2781), 
and frames (V2020) provided on April 26, 2023. 
 
You asked the Plan to pay for polycarbonate lenses (V2784), progressive lenses (V2781), and frames (V2020). 
You say that the provider told you that they called the Plan, and the services should be covered. The Plan 
denied your request. The Plan says the Plan does not cover out-of-network vision care 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 covers these services when the services are obtained in-network. 
 
We looked at the file and the Plan's rules. The Plan rules say that non-Medicare-covered routine eye exams and 
eyewear must be obtained from a provider in the Plans vision vendor network. Services obtained from vendors 
outside this network are not covered. Based on this information, we decided that the Plan's rules for coverage 
of polycarbonate lenses (V2784), progressive lenses (V2781), and frames (V2020) have not been met. 
Therefore, we decided that the Plan does not have to pay for polycarbonate lenses (V2784), progressive lenses 
(V2781), and frames (V2020) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  dental services provided by Mid Penn Oral Surgery on July 
29, 2022. 
 
You asked the Plan to pay for  dental services. You say that this was medically necessary. The Plan denied 
your request. The Plan says the provider has been precluded from Medicare. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for  dental 
services provided by Mid Penn Oral Surgery on July 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by an out-of-network provider on 
February 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that you received services from a participating 
provider. 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 dental services provided by an out-of-network provider on February 21, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88112 billed with diagnosis code Z15.01 
provided on February 7, 2023. 
 
You asked the Plan to pay for procedure code 88112. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that health plans, physicians, hospitals, and other health 
care providers must comply with the Official International Classification of Disease, 10th Edition, Clinical 
Modification (ICD-10-CM) Coding Guidelines.  
 We looked at the file and Medicare rules. In this case, coding guidelines state that codes from category Z15 
should not be used as principal or first-listed codes. Therefore, we decided that the Plan does not have to pay 
for procedure code 88112 billed with diagnosis code Z15.01 provided on February 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 18, 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 you have a $0 copay up to the $2,000 allowance for all covered dental services.  
You pay 100% of charges beyond the $2,000 allowance or if you exceed a service limit. 
 
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 dental services provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hearing aid (V5221) and a dispensing fee (V5240) 
provided on April 12, 2023. 
 
You asked the Plan to pay for a hearing aid (V5221) and a dispensing fee (V5240). You say that the medically 
needed hearing aids were provided due to nerve damage related to left sided acoustic neuroma. You also say 
that none of the listed hearing aids would meet your needs and would be inappropriate. The Plan denied your 
request. The Plan says There is no coverage for hearing aids when received from a provider other than the Plan 
hearing. The Plan also says that the hearing benefit is not covered if the services are not ordered through this 
designated vendor. 
 
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 hearing aids are obtained from an in-network provider.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of a hearing aid (V5221) and a dispensing fee (V5240) have not been met. Therefore, we decided that 
the Plan does not have to pay for a hearing aid (V5221) and a dispensing fee (V5240) provided on April 12, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral  comprehensive series of radiographic images 
(D0210) provided on February 9, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that if the 
insurance company does not cover the services, the provider should ask whether or not the enrollee can afford 
to pay for the service. You also say that you should not be charged if they did not authorize something out of 
your insurance coverage. The Plan denied your request. The Plan says your benefit for the intraoral  
comprehensive series of radiographic images 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 intraoral  comprehensive series of radiographic images was exhausted on date of 
service January 3, 2022. Therefore, we decided that the Plan does not have to pay for an intraoral  
comprehensive series of radiographic images (D0210) provided on February 9, 2023.  
 
Your complaint about the dentist you saw is not a valid appeal for medical coverage. This part of your 
complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision 
about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for parenteral nutrition solution 10 grams lipids (B4185), 
parenteral nutrition solution 52 to 73 grams of protein (B4193), premix of parenteral nutrition supply kit 
(B220), and parenteral nutrition administration kit (B4224) provided from March 1, 2023, to March 6, 2023. 
 
  You asked the Plan to pay for parenteral nutrition solution 10 grams lipids (B4185), parenteral nutrition 
solution 52 to 73 grams of protein (B4193), premix of parenteral nutrition supply kit (B220), and parenteral 
nutrition administration kit (B4224). You say that you are appealing with supporting records. The Plan denied 
your request. The Plan says the records do not support the service billed. The Plan also says that the requested 
information was not received. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of parenteral nutrition solution 10 grams 
lipids (B4185), parenteral nutrition solution 52 to 73 grams of protein (B4193), premix of parenteral nutrition 
supply kit (B220), and parenteral nutrition administration kit (B4224) have been met. The submitted medical 
records do not include a delivery ticket for the billed date of service. This means the service cannot be verified. 
Therefore, the billed supply code cannot be verified. The record shows that multiple attempts were made to 
contact the provider for additional information. The record also shows the submitted details of delivery ticket 
date does not match the delivery service tracking information date. This means that evidence of delivery cannot 
be verified. Therefore, we decided that the Plan does not have to pay for parenteral nutrition solution 10 grams 
lipids (B4185), parenteral nutrition solution 52 to 73 grams of protein (B4193), premix of parenteral nutrition 
supply kit (B220), and parenteral nutrition administration kit (B4224) provided from March 1, 2023, to March 
6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral  comprehensive series of radiographic images 
(D0210) provided on April 11, 2023. 
 
You asked the Plan to pay for the intraoral  comprehensive series of radiographic images. You say that you 
informed the radiographer you already had x-rays taken and they tried to reach the previous provider but could 
not get through. You also say that you were told the x-rays would be taken without charge by the provider but 
you have received a denial for the x-rays.  The Plan denied your request. The Plan says your benefit for the 
intraoral  comprehensive series of radiographic images 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 intraoral  comprehensive series of radiographic images was exhausted on date of 
service February 23, 2023. Therefore, we decided that the Plan does not have to pay for the intraoral  
comprehensive series of radiographic images (D0210) provided on April 11, 2023.  
 
Your complaint about the x-rays taken without charge by the provider is not a valid appeal for medical 
coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not 
permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a consultation - diagnostic service provided by dentist 
or physician other than requesting dentist or physician (D9310) provided on April 26, 2023. 
 
You asked the Plan to pay more for the consultation. You say that you were not informed of a provider list and 
you did not know that the provider was out-of-network. The Plan denied your request. The Plan says you are 
responsible for any charged amount above the Plans cost-sharing amount when your services are received 
from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.  The Plan has confirmed that the provider is no longer billing you $203, just the $125 which is the difference 
between the allowed amount of $78 for the procedure code and the billed amount of $203. Therefore, we 
decided that the Plan does not have to pay more for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a consultation - diagnostic service provided by dentist or 
physician other than requesting dentist or physician (D9310) provided on February 25, 2023. 
 
You asked the Plan to pay for the consultation. You say that you disagree with the benefit structure. You also 
say that for the dentist to perform services a consultation is necessary. The Plan denied your request. The Plan 
says D9310 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 a 
consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician 
(D9310) provided on February 25, 2023.