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

 
We decided that the Plan does not have to pre-approve retainer crown - porcelain/ceramic (x2) (D6740) and 
retainer crown - porcelain fused to noble metal (x1) (D6752). 
 
You asked the Plan to pre-approve 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 pre-approve retainer crown - porcelain/ceramic (x2) (D6740) and retainer crown - porcelain fused to noble metal (x1) (D6752).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal care services provided on October 10, 2022, to 
October 23, 2022. 
 
You asked the Plan to pay for the personal care services. You say that a hearing before an administrative law 
judge (ALJ) was not necessary because the Plan agreed to pay for the claims with some exceptions from 
January 17, 2022, through July 2, 2022. The Plan denied your request. The Plan says Original Medicare is 
responsible for payment. 
 
  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the personal care services provided on October 10, 2022, to 
October 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation with a medicinal agent  per quadrant 
(D4921). 
 
You asked the Plan to pre-approve the gingival irrigation with a medicinal agent. You say that the procedure 
cost is $400 and you live off $800 a month. You also say that you are currently in pain. The Plan denied your 
request. The Plan says you are only covered for the dental services, codes and limits listed in the medical 
benefits chart. 
 
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 
gingival irrigation with a medicinal agent  per quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for reline complete mandibular denture (D5751) provided on 
April 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that you cannot have just part of the dentures 
relined, as it has to be both to get a good fit.  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 April 25, 2023. 
Therefore, we decided that the Plan does not have to pay for reline complete mandibular denture (D5751) 
provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone replacement graft for ridge preservation (D7953) 
and facial surgery for upper right quadrant (D7950). 
 
You asked the Plan to pre-approve bone replacement graft and facial surgery. 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 bone 
replacement graft for ridge preservation (D7953) and facial surgery for upper right quadrant (D7950).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom foot orthotics.  
 
You asked the Plan to pre-approve the custom foot orthotics. You say that the enrollee has significant forefoot 
deformity with difficulty with shoe gear. You also say that the custom foot orthotics are medically necessary. 
The Plan denied your request. The Plan says this item is not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve custom foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for compression stockings (A6530) provided on April 26, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that sometimes gradient compression 
stockings are covered. The Plan denied your request. The Plan says multiple attempts were made to obtain the 
medical records from the provider. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 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 the compression stockings have been 
met. The medical records were not provided to support the service requested. Without the medical records we 
are unable to determine whether criteria for coverage have been met and whether payment is due. The Plan also 
provided evidence of reasonably attempting to obtain the medical records. Therefore, we decided that the Plan 
does not have to pay for compression stockings (A6530) provided on April 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim and that the services requested are medically necessary. The Plan denied your request. The Plan 
says the services requested are not covered 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 dental 
services on April 4, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment, methadone and a take home 
supply of methadone; up to 7 additional day supply provided on April 10, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone and a take home supply of methadone; 
up to 7 additional day supply. You say that a referral, authorization, precertification or notification is not 
required. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in 
advance. 
 
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 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for medication assisted treatment, methadone and a take home 
supply of methadone; up to 7 additional day supply provided on April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial lower denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that this is medically necessary. 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 24, 2022. 
Therefore, we decided that the Plan does not have to pre-approve partial lower denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a resin-based composite (D2335) of four or more 
surfaces anterior, a resin-based composite (D2393) of three surfaces posterior, and a resin-based composite of 
two surfaces posterior (D2392) provided on March 30, 2023.  
 
You asked the Plan to pay more for the dental services. You say that you were able to confirm on the internet 
that this provider was in-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. 
Therefore, we decided that the Plan does not have to pay more for a resin-based composite (D2335) of four or 
more surfaces anterior, a resin-based composite (D2393) of three surfaces posterior, and a resin-based 
composite of two surfaces posterior (D2392) provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care provided on June 23, 2023. 
 
You asked the Plan to waive the copayment for urgent care. You say that you want to appeal the amount being 
charged. 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 $50 
copayment for urgently needed services. 
 
You have been asked to pay a $50 copayment for urgent care. This item/service falls within the urgently 
needed 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 urgent care provided on 
June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for frames (V2020), trifocal eyeglasses (V2300), progressive 
lenses (V2781), polycarbonate lenses (V2784) and anti-reflective lenses (V2570) provided on May 1, 2023.  
You asked the Plan to pay for frames (V2020), trifocal eyeglasses (V2300), progressive lenses (V2781), 
polycarbonate lenses (V2784) and anti-reflective lenses (V2570). You say that the yearly routine eye 
examination is free. You also say that the Plan gives you $400 per year toward eyewear to use at in-network 
providers. The Plan denied your request. The Plan says they covered $400 (per the benefit) towards the cost of 
the eyewear (glasses). 
 
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 . 
 
We looked at the file and the Plan's rules. The Plan rules say they pay up to $400 per year for eyeglasses and 
lenses. The record shows this benefit was exhausted with this service. Based on this information, we decided 
that the Plan's rules for coverage of frames (V2020), trifocal eyeglasses (V2300), progressive lenses (V2781), 
polycarbonate lenses (V2784) and anti-reflective lenses (V2570) have not been met. Therefore, we decided that 
the Plan does not have to pay for frames (V2020), trifocal eyeglasses (V2300), progressive lenses (V2781), 
polycarbonate lenses (V2784) and anti-reflective lenses (V2570) provided on May 1, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
December 15, 2022, to December 27, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that you do not agree with 
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 $275 
copayment each day, for days 1 to 6, for Medicare-covered hospital care each time you are admitted, and a $0 
copayment for additional Medicare-covered days. 
 
 You have been asked to pay a $1650 copayment for the inpatient hospital stay ($275 copayment x 6 days = 
$1650). This item/service falls within the inpatient hospital care 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 the inpatient hospital stay provided from December 15, 2022, to December 27, 
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 May 30, 2023. 
 
You asked the Plan to pay for the limited oral evaluation - problem focused. You say that you went to the 
dentist because your tooth had broken off. You also say that based on that information from the doctor you 
chose not to proceed with the tooth being worked on and discussed other options. The Plan denied your 
request. The Plan says your benefit for the limited oral evaluation - problem focused 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 was exhausted on dates of service January 3, 2023, and February 
7, 2023. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem 
focused (D0140) provided on May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a pontic (D6245), abutment supported 
crown (D6058) and abutment supported retainer (D6068). 
 
You asked the Plan to waive the coinsurance for an abutment supported crown and abutment supported 
retainer. 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 for implant services.  
 
You have been asked to pay 50% coinsurance for an abutment supported crown and abutment supported 
retainer. A pontic is not a covered service. This item/service falls within the implant 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 coinsurance for a pontic (D6245), abutment supported crown (D6058) and 
abutment supported retainer (D6068).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0315U) provided on March 6, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 0315U is not supported in the medical record. Specifically, the date of service billed 
does not match the date the specimen was collected. Based on this information, we decided that Medicare rules 
for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for 
lab services (0315U) provided on March 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 10035 billed for date of service May 18, 
2023.  
 
You asked the Plan to pay for procedure code 10035. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 10035 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 10035 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 10035 billed for date of service May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) and a retainer crown (D6752) provided 
on February 23, 2023. 
 
You asked the Plan to pay for core buildup (D2950) and a retainer crown (D6752). You say that you probably 
would not have had the procedure without initial knowledge. You also say you paid what you were told would 
be the balance due. The Plan denied your request. The Plan says core buildup is not a covered benefit. The Plan 
also says that a retainer crown (D6752) is excluded from this 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, core buildup is not among those 
covered under this benefit. Though the Plan offers a dental benefit in excess of Medicare coverage, certain 
limitations apply. The record shows your benefit for a retainer crown (D6752) was exhausted with this date of 
service, which is February 23, 2023. Therefore, we decided that the Plan does not have to pay for core buildup 
(D2950) and a retainer crown (D6752) provided on February 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an alveoloplasty (D7320) provided on November 14, 2022. 
 
You asked the Plan to pay for an alveoloplasty (D7320) . You say that the provider advised him all the services 
completed would be covered and therefore he had no reason to believe this would be denied by the Plan. The 
Plan denied your request. The Plan says this 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 an 
alveoloplasty (D7320) provided on November 14, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance provided on April 25, 2023. 
 
You asked the Plan to waive the copayment for ambulance. You say that you say that it is unfair for older 
people to have to pay copays. 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 $265 
copayment for ambulance services. 
 
You have been asked to pay a $265 copayment for ambulance. This item/service falls within the ambulance 
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 ambulance provided on 
April 25, 2023.