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

 
We decided that the Plan does not have to pay for the limited oral evaluation-problem focused (D0140), 
intraoral-periapical first radiographic image (D0220), endodontic therapy, of a molar tooth (excluding final 
restoration) (D3330), and the prefabricated post and core in addition to crown (D2954) provided on  
February 20, 2023. 
 
You asked the Plan to pay for these dental items/services. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says the dental items/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 dental items/services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental items/services provided are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the limited oral evaluation-problem focused (D0140), intraoral-periapical first radiographic image 
(D0220), endodontic therapy, of a molar tooth (excluding final restoration) (D3330), and the prefabricated post 
and core in addition to a crown (D2954) provided on February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection and specialist visit provided on 
February 22, 2023. 
 You asked the Plan to waive the copayment for an injection and specialist visit. You say that you disagree with 
the cost share applied. 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 20% 
coinsurance for Medicare Part B prescription drugs a $35 copayment for each specialist visit.  
 
You have been asked to pay $59.73 for an injection and specialist visit. This total includes $24.73 coinsurance, 
which is 20% of the allowed amount for a Medicare Part B drug injection ($123.64 allowed x 20% = $24.73) 
and a $35 copayment for a specialist visit. The injection falls within the Medicare Part B prescription drugs 
benefit category. The specialist visit falls within the physician/practitioner 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 injection and specialist visit provided on February 22, 
2023.
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 June 23, 2023. 
 
You asked the Plan to pay for the core buildup, including any pins when required (D2950) provided on June 
23, 2023. You say that if you have to have a crown put on you feel it should pay for whatever is required to 
complete the crowning. The Plan denied your request. The Plan says this service is not a covered benefit under 
your dental 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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core buildup, 
including any pins when required (D2950) provided on June 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) and a resin-based composite (D2393) for 
tooth #28 and #29 provided by an out-of-network provider on March 21, 2023, and March 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that according to your documents the provider is an 
in-network 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. Also, the dental directory is 
updated each month and the provider has been an out-of-network provider since August 31, 2022. 
 
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 a cleaning (D1110) and a resin-based composite (D2393) for tooth #28 and #29 provided by an out-
of-network provider on March 21, 2023, and March 22, 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 
(A0998) provided on March 15, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and were unable to get yourself up so your granddaughter called the fire department. You also say the 
paramedics got you up, took an electrocardiogram (EKG) and you declined the transport to the hospital. 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 15, 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 (A0998) provided on March 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided on April 5, 2023. 
 
You asked the Plan to pay for the dental services. You say that a new pair of dentures were medically necessary 
because your previous dentures were damaged beyond repair. The Plan denied your request. The Plan says 
your benefit for the requested items or services 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 for a complete upper denture (D5110) and a complete lower denture (D5120) on April 15, 
2022; therefore, your benefit for the requested items or services was exhausted on the date of service of April 
15, 2022. Therefore, we decided that the Plan does not have to pay for a complete upper denture (D5110) and a 
complete lower denture (D5120) provided on April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids (V5298) purchased on 
April 20, 2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says these items are not payable as 
they were purchased from an out-of-network provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract states that hearing aids are only 
covered when purchased from the Plans select hearing aid provider. However, the hearing aids in this case 
were purchased from out-of-network provider. Therefore, we decided that the Plan does not have to issue 
reimbursement for the hearing aids (V5298) purchased on April 20, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays provided on November 03, 2022, to November 04, 
2022. 
 
You asked the Plan to pay for x-rays. You say that you are requesting reconsideration stating the equipment 
utilized for this testing can only be processed by your facility and ask that the plan allow the denied claim to be 
reprocesses as an in-network service. 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 x-rays provided on 
November 03, 2022, to November 04, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on March 25, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you are an 
insulin-dependent diabetic and your blood sugar bottomed out while you were sleeping. The emergency 
medical service arrived and administered an intravenous of glucose and you soon came to and declined the 
transport to the hospital. 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 25, 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 (A0998) provided on March 25, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit provided on May 25, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit. You say that this is supported in the records. 
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 hospital outpatient 
clinic visit provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), the intraoral radiographic 
images (D0220 and D0230) and a cone beam (D0367) provided by an out-of-network provider on June 26, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you were referred to the out-of-network 
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. Also, it was verified that you were 
referred to an in-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 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 a limited oral evaluation (D0140), the intraoral radiographic images (D0220 and D0230) and a cone 
beam (D0367) provided by an out-of-network provider on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an immediate upper denture (D5130) and an immediate 
lower denture (D5140) provided by an out-of-network provider on January 26, 2023. 
  You asked the Plan to pay for the dental services. You say that the dental services were mandatory for the 
enrollee's health reasons and there was no time to worry about the provider being in-network. 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 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 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 an immediate upper denture (D5130) and an immediate lower denture (D5140) provided by an 
out-of-network provider on January 26, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a hospital outpatient clinic visit, and related services 
provided on May 25, 2023. 
 
You asked the Plan to pay for a hospital outpatient clinic visit, and related services. You say that this is 
supported in the records. 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 hospital outpatient 
clinic visit, and related services provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration, natural teeth-resorbable 
barrier, per site (D4266) and the bone replacement graft (D7953) provided on January 24, 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 covered under the 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit.  
  
 
 
 
Therefore, we decided that the Plan does not have to pay for the guided tissue regeneration, natural teeth-
resorbable barrier, per site (D4266) and the bone replacement graft (D7953) provided on January 24, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a screening mammogram, and screening digital breast 
tomosynthesis provided on May 23, 2023. 
 
You asked the Plan to pay for a screening mammogram, and screening digital breast tomosynthesis. You say 
that this is supported in the records. 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 screening 
mammogram, and screening digital breast tomosynthesis provided on May 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) 
provided on June 13, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service January 11, 2023.  
  
 
 
 
Specifically, the Plans contract states that one intraoral x-ray is covered per calendar year. You previously 
received an intraoral x-ray on January 11, 2023, less than one year prior, which was paid for by the Plan. 
Therefore, you have exhausted the allowable benefit for this service. Therefore, we decided that the Plan does 
not have to pay for the intraoral-periapical first radiographic image (D0220) provided on June 13, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on February 26, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that these services were rendered in good will. 
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 skilled nursing facility 
provided on February 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99406 provided on February 10, 2023. 
 
You asked the Plan to pay for procedure code 99406. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the code at issue is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99406 is Smoking and tobacco use cessation counseling 
visit; intermediate, greater than 3 minutes up to 10 minutes. 
 
We find that CPT code 99406 is not supported in the medical record. Specifically, the code definition is time-
based, and the records submitted for review do not document the total time spent providing the services 
described by this code. Based on this information, we decided that Medicare rules for coverage of procedure code 99406 have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 
99406 provided on February 10, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote interrogation device evaluation provided on June 
02, 2023. 
 
You asked the Plan to pay for a remote interrogation device evaluation. You say that this is supported in the 
records. 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 remote interrogation 
device evaluation provided on June 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a remote interrogation device evaluation provided on June 
05, 2023. 
 
You asked the Plan to pay for a remote interrogation device evaluation. You say that this is supported in the 
records. 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 remote interrogation 
device evaluation provided on June 05, 2023.