Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network diagnostic colonoscopy 
provided on January 26, 2023. 
 
You asked the Plan to waive the copayment for an in-network diagnostic colonoscopy. You say that this is a 
billing error, there should not be a 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 $290 
copayment for outpatient hospital services. 
 
You have been asked to pay a $290 copayment for an in-network diagnostic colonoscopy. This item/service 
falls within the outpatient hospital 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 an in-network diagnostic colonoscopy provided on January 26, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical supplies provided on February 22, 2023. 
 
You asked the Plan to pay for surgical supplies. You say that the member is in an approved authorized nursing 
facility, and they wouldnt need an authorization. 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 surgical supplies 
provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pulp cap (D3120), localized delivery of antimicrobial 
agents (D4381 x 3) and gingival irrigation with a medicinal agent (D4921 x 2) provided from March 27, 2023, 
to March 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denial. The Plan denied 
your request. The Plan says these services are not covered under the Plan's 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 pay for the pulp 
cap (D3120), localized delivery of antimicrobial agents (D4381 x 3) and gingival irrigation with a medicinal 
agent (D4921 x 2) provided from March 27, 2023, to March 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extractions, erupted tooth requiring removal of bone and/or 
sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210), guided tissue 
regeneration - resorbable barrier, per site (D4266), and bone replacement graft for ridge preservation - per site 
(D7953) provided on April 11, 2023. 
 
You asked the Plan to pay for the extractions, guided tissue regeneration - resorbable barrier, and bone 
replacement graft for ridge preservation. You say that you were told by two different Plan personnel that all 20 
teeth would be covered due to health reasons. You also say that you disagree with the denial and would like the 
Plan do reconsider payment. The Plan denied your request. The Plan says your benefit for the extractions, 
erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal 
flap if indicated (D7210) has already been exhausted. The Plan also says the guided tissue regeneration - 
resorbable barrier, per site (D4266), and bone replacement graft for ridge preservation (D7953) are excluded 
from coverage.  
 
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 guided tissue regeneration - resorbable barrier, per site, and 
bone replacement graft for ridge preservation are not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pay for and guided tissue regeneration - resorbable barrier, per site 
(D4266 ), and bone replacement graft for ridge preservation - per site (D7953) provided on April 11, 2023. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limits apply. The record shows 
your benefit for extractions, erupted tooth requiring removal of bone and/or sectioning of tooth and including 
elevation of mucoperiosteal flap if indicated (D7210) was exhausted on date of service April 11, 2023. 
Therefore, we decided that the Plan does not have to pay for extractions, erupted tooth requiring removal of 
bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated (D7210) provided 
on April 11, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye examination (92004) and a determination of 
refractive state (92015) provided on June 13, 2022. 
 
You asked the Plan to pay for a medical eye examination (92004) and a determination of refractive state 
(92015). You say that you did not know the refraction charges are out of network. 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 medical eye 
examination (92004) and a determination of refractive state (92015) provided on June 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite (D2391) and the endodontic 
therapy (D3320) for tooth #29 provided on February 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were told the dental procedure would be 
100% covered and you relied on what the Plan told you. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. Also, it was verified you were told the 
proper benefits and provider eligibility. 
 
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 $171 for dental services on January 30, 2023. The Plan paid $329 for dental services on 
February 7, 2023. For the year of 2023 the Plan paid $500 ($171 paid + $329 paid) for dental services. 
Therefore, your maximum allowable dental benefit for the year of 2023 was exhausted on the date of service of 
February 7, 2023. Therefore, we decided that the Plan does not have to pay for the resin-based composite 
(D2391) and the endodontic therapy (D3320) for tooth #29 provided on February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an occlusal orthotic device, by report (D7880) provided on 
September 19, 2022. 
 
You asked the Plan to pay for the occlusal orthotic device, by report. You say that you would like the services 
to be covered, paid in full and reimbursed. The Plan denied your request. The Plan says D7880 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 occlusal orthotic device, by report 
services is not among those covered under this benefit. Therefore, we decided that the Plan does not have to 
pay for an occlusal orthotic device, by report (D7880) provided on September 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins when required (D2950) 
provided on February 20, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required. You say how can your 
benefit be exhausted when you have rarely made a dental claim, and certainly not any this benefit year. The 
Plan denied your request. The Plan says your benefit for the core buildup, including any pins when required 
$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 core buildup, including any pins was exhausted on date of service March 1, 2023. 
The benefit maximum of $1,000 was met with claim ending in 2700 for date of service January 25, 2023 
allowing a payment of $125.00, and services rendered with the claim ending in 7500 for date of service March 
01, 2023 allowing a payment of $875.00 for services rendered exhausting the $1,000.00 annual maximum 
allowed for the 2023 plan. Therefore, we decided that the Plan does not have to pay for core buildup, including 
any pins when required (D2950) provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an allergen immunotherapy provided on March 07, 2023. 
 
You asked the Plan to pay for an allergen immunotherapy. 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 an allergen 
immunotherapy provided on March 07, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for deluxe frames (V2025), progressive lens (V2781), 
photochromatic lens (V2744), anti-reflective coating (V2750), and ultraviolet (u-v) lens (V2755) purchased on 
March 7, 2023. 
 
You asked the Plan to pay more for deluxe frames (V2025), progressive lens (V2781), photochromatic lens 
(V2744), anti-reflective coating (V2750), and ultraviolet (u-v) lens (V2755). You say that your eye problems 
have been going on since 2021, and as a result you had to see an eye doctor within the Plan group for the 
glasses. The Plan denied your request. The Plan says the glasses/frame and less package has not been denied 
and claim is paying correctly. 
 
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 a $100 benefit toward the purchase and fitting of eyeglasses and 
pair of lenses or contact lenses at a network optical provider (1 per calendar year). 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $100 benefit toward the purchase 
and fitting of eyeglasses and pair of lenses or contact lenses at a network optical provider (1 per calendar year). 
The record shows that the $100 discount has been applied. The record also shows that there is a 20% discount 
applied to the billed amount. Therefore, the Plan has processed this claim correctly. Based on this information, 
we decided that the Plan's rules for coverage of deluxe frame (V2025), progressive lens (V2781), 
photochromatic lens (V2744), anti-reflective coating (V2750), and ultra violet (u-v) lens (V2755) have not 
been met. Therefore, we decided that the Plan does not have to pay more for deluxe frames (V2025), 
progressive lens (V2781), photochromatic lens (V2744), anti-reflective coating (V2750), and ultraviolet (u-v) 
lens (V2755) purchased on March 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 00812-P3 billed for date of service January 
24, 2023. You asked the Plan to pay for the billed services. You say that the length of time was submitted on the claim. 
The Plan denied your request. The Plan says the required modifier is missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT code 00812-P3 was provided by a CRNA. The claim was not billed with a modifier 
indicating a qualified non-physician anesthetist. Based on this information, we decided that Medicare rules for 
coverage of the billed services have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 00812-P3 billed for date of service January 24, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the enrollee's needs can be met in an alternate level of care.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) for tooth #20 provided on January 
30, 2023. 
 
You asked the Plan to pay for the dental service. You say that the dentist said the core buildup was needed to 
install the crown and you are appealing the denied dental service. The Plan denied your request. The Plan says 
the denial of payment for this service is correct, because the core buildup 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 core 
buildup (D2950) for tooth #20 provided on January 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites (D2335) for tooth #8 and #10 
provided on March 12, 2023. 
 
You asked the Plan to pay for the dental services. You say that your dentist told you that the fillings were 
necessary. The Plan denied your request. The Plan says your combined dental allowance 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 $1,000 for dental services on January 12, 2023; therefore, your annual dental benefit for 
the year of 2023 was exhausted on the date of service of January 12, 2023. Therefore, we decided that the Plan 
does not have to pay for the resin-based composites (D2335) for tooth #8 and #10 provided on March 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite-three surfaces, posterior (D2393) 
provided on March 21, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not covered under the 
supplemental dental policy.  
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The service you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the resin-based composite-three 
surfaces, posterior (D2393) provided on March 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray exam of the shoulder (73030), office visit (99203), 
and the therapeutic activities (97530) provided on February 6, 2023. 
 
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 these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the x-ray exam of the shoulder (73030), office visit (99203), and the 
therapeutic activities (97530) provided on February 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the surgical removal of an 
erupted tooth (D7210), deep sedation (D9222 and D9223), the therapeutic drugs (D9610), and the unspecified 
adjunctive procedure (D9999) provided by an out-of-network provider on February 17, 2023. 
 
You asked the Plan to pay for the dental services. You say that it was a medical emergency that the enrollee 
received the dental services, and the enrollee was out of state. The Plan denied your request. The Plan says the 
limited oral evaluation and the surgical removal of an erupted tooth were received from an out-of-network 
provider and are not covered by your supplemental benefits. The deep sedation, the therapeutic drugs, and the 
unspecified adjunctive procedure are not covered by the Plan. Also, it was verified that you were advised of 2 
network providers that were in the same service area as the 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. 
 
The record shows the enrollee received the requested dental services from an out-of-network provider. Though 
the Plan offers a dental benefit in excess of Medicare coverage, the limited oral evaluation and the surgical 
removal of an erupted tooth are not covered under this benefit when received from an out-of-network provider. 
The deep sedation, the therapeutic drugs, and the unspecified adjunctive procedure are not covered under the 
Plans dental benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation 
(D0140), the surgical removal of an erupted tooth (D7210), deep sedation (D9222 and D9223), the therapeutic 
drugs (D9610), and the unspecified adjunctive procedure (D9999) provided by an out-of-network provider on 
February 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) provided on November 30, 2022. 
 
You asked the Plan to pay for the dental service. You say that you are appealing the denied dental service. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because the cone beam 
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 a cone 
beam (D0380) provided on November 30, 2022.