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

 
We decided that the Plan does not have to pay for computed tomography (CT) of the thorax provided on 
February 28, 2023. 
 
You asked the Plan to pay for computed tomography (CT) of the thorax. You say that the CT was medically 
necessary. 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 computed tomography 
(CT) of the thorax provided on February 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the frames and lenses provided on March 27, 2023. 
 You asked the Plan to pay for the frames and lenses. You say that you never received any information about the 
provider. The Plan denied your request. The Plan says the service was not a covered benefit. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the frames and lenses have not been met. 
Therefore, we decided that the Plan does not have to pay for the frames and lenses provided on March 27, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified periodontal procedure, by report (D4999) 
provided on January 4, 2023. 
 
You asked the Plan to pay for the unspecified periodontal procedure, by report. The Plan denied your request. 
The Plan says this service is not included in your dental 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 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 
unspecified periodontal procedure, by report (D4999) provided on January 4, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an IRF stay provided from March 14, 2023, 
to March 21, 2023. 
 
You asked the Plan to waive the copayment for an IRF stay. You say that you met your maximum out-of-
pocket prior to this claim and feel you should not have cost share. 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 $240 
copayment per day for days 1 to 5 and $0 for day 6 and beyond for a network hospital stay.  
 
You have been asked to pay a $848.41 copayment for an IRF stay. This amount is less than the standard 
copayment for an inpatient hospital stay because your maximum out-of-pocket was met with the processing of 
this claim. 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 an IRF stay provided from March 14, 2023, to March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core buildup (D2950) and additional procedures to 
customize a crown to fit under an existing partial denture (D2971) provided from February 1, 2023, to February 
22, 2023. 
 
You asked the Plan to pay for the dental services. You say that a core buildup is an essential step in a crown 
restoration and should be bundled into the crown treatment. 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 core 
buildup (D2950) and additional procedures to customize a crown to fit under an existing partial denture 
(D2971) provided from February 1, 2023, to February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown placement on tooth #13 (D2740) provided on May 
10, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 September 30, 2021. 
Therefore, we decided that the Plan does not have to pay for a crown placement on tooth #13 (D2740) provided 
on May 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for computed tomography (CT) of the thorax. 
provided on March 03, 2023. 
 
You asked the Plan to waive the copayment for computed tomography (CT) of the thorax.. You say that you 
should not be responsible to pay this. 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 $150 
copayment for a CT scan. 
 
You have been asked to pay a $150 copayment for computed tomography (CT) of the thorax.. This item/service 
falls within the a CT scan 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. You have been asked to pay $116.86, which is less than the standard $150 copayment 
amount. Therefore, we decided that the Plan does not have to waive the copayment for computed tomography 
(CT) of the thorax. provided on March 03, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99285 billed for date of service February 14, 
2023.   
You asked the Plan to pay for procedure code 99285. You say that this service was medically necessary. 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 submitted claims in which the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 3, unless there is evidence justifying the excess 
units.  
 
In this case, the MUE for CPT code 99285 is 1. The MAI value for this code is 3. You billed 2 units of this 
code, exceeding the MUE. You did not provide all the required evidence showing that the excess units were 
actually provided, were correctly coded, and were medically necessary. Based on this information, we decided 
that Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99285 billed for date of service February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthodontic retention (D8680) provided on January 10, 
2023. 
 
You asked the Plan to pay for the dental services. You say that this procedure was necessary after your fall and 
your teeth shifted. 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
orthodontic retention (D8680) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the crown (D2740), core buildup (D2950) and surgical 
extraction (D7210) provided on January 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you thought your provider was in-
network. The Plan denied your request. The Plan says these services are either not covered under your dental 
plan or 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. 
Additionally, D2950 is not covered under any circumstance. Therefore, we decided that the Plan does not have 
to pay more for the crown (D2740), core buildup (D2950) and surgical extraction (D7210) provided on January 
26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete series of x-ray images (D0210) provided on 
March 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were not aware you exceeded the benefit 
limitation, and your provider required this procedure to evaluate your teeth. 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 December 17, 2019. 
Therefore, we decided that the Plan does not have to pay for the complete series of x-ray images (D0210) 
provided on March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid provided on November 9, 2022. 
 
You asked the Plan to pay for the hearing aid. You say that you needed a hearing aid after being diagnosed 
with tinnitus and hearing loss. You say you found the in-network vendor to be substandard and returned to the 
referred out-of-network provider. The Plan denied your request. The Plan says the service is not a covered 
benefit. 
 
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 received in-network.  
 
We looked the file and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage 
of the hearing aid have not been met. Specifically, the provider was out-of-network. Therefore, we decided that 
the Plan does not have to pay for the hearing aid provided on November 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns - porcelain/ceramic (D2740) provided on March 6, 
2023. 
 
You asked the Plan to pay for the crowns. You say that the two crowns are very visible since theyre on your 
front teeth and you dont understand why they arent covered. The Plan denied your request. The Plan says 
there is no coverage for crowns. 
 
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 crowns - 
porcelain/ceramic (D2740) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drugs or medicaments dispensed in the office for home use 
(D9630), and periodontal maintenance (D4910) provided on April 18, 2022, and October 3, 2022. 
 
You asked the Plan to pay for the drugs or medicaments and periodontal maintenance. You say that the dental 
cleanings are part of your dental coverage and you did not use any of the drugs. You also say that you 
purchased your own antibiotics. The Plan denied your request.  The Plan says your benefit for the periodontal maintenance has already been exhausted. The Plan also says that 
the drugs or medicaments and periodontal maintenance are not covered. 
 
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 drugs or medicaments are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for drugs or 
medicaments provided on April 18, 2022, and October 3, 2022. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the periodontal maintenance was exhausted on date of service April 18, 2023. The Plan 
submitted payment for the periodontal cleaning that you received on April 18, 2022 as this was the first 
periodontal cleaning you received during the calendar year. Therefore, we decided that the Plan does not have 
to pay for the periodontal maintenance (D4910) provided on April 18, 2022, and October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the resin-based composite (D2330) for tooth #26 and 
the endodontic therapy (D3310) for tooth #26 provided on January 23, 2023. 
 
You asked the Plan to pay more for the dental service. You say that when you checked your covered it showed 
the services being covered at 100%. The Plan denied your request. The Plan says your annual dental maximum 
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 $113 for dental services on April 25, 2023, which was processed prior to the claim for 
January 23, 2023. On January 23, 2023, the Plan paid $887 for dental services. For the year of 2023 the Plan 
paid $1,000 ($113 paid + $887 paid) for dental services; therefore, your annual dental maximum benefit for the 
year of 2023 was exhausted on the date of service of January 23, 2023. Therefore, we decided that the Plan 
does not have to pay more for the resin-based composite (D2330) for tooth #26 and the endodontic therapy 
(D3310) for tooth #26 provided on January 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on March 21, 2023. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. 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 periodic oral evaluation and cleaning 
(D0120, D1110) provided on March 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 20, 
2023. 
 
You asked the Plan to pay for the dental service. You say that the Plan has not paid for any dental services in 
2023. 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 the Plan paid for a limited oral evaluation (D0140) on April 14, 2023; therefore, your benefit for the 
requested item or service was exhausted on the date of service of April 14, 2023. Therefore, we decided that 
the Plan does not have to pay for a limited oral evaluation (D0140) provided on April 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the office visit provided on March 14, 
2023. 
 
You asked the Plan to waive the copayment for the office visit. You say that you say this was your yearly eye 
exam. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for each visit to a specialist, such as an ophthalmologist or optometrist, for Medicare-covered 
benefits.  
 
 You have been asked to pay a $40 copayment for the office visit. The office visit falls within the vision care 
benefit category. The medical records show diagnoses of drusen, keratoconjunctivitis, and pseudophakia which 
makes the visit medical in nature. 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 office visit 
provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010) for tooth 
#21, the extractions (D7140 and D7210) for tooth #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #18, 
#19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29, and the alveoloplasty (D7310) on 2 quadrants 
provided on January 23, 2023. 
 
You asked the Plan to pay for the dental services. You say that the dental services were medically necessary for 
your medical condition that you have. The Plan denied your request. The Plan says the denial of payment for 
these services is correct, because the surgical placement of implant body, extractions, and the alveoloplasty are 
not covered by the Plan. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
surgical placement of implant body (D6010) for tooth #21, the extractions (D7140 and D7210) for tooth #2, #3, 
#4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #15, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, and #29, 
and the alveoloplasty (D7310) on 2 quadrants provided on January 23, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 17, 2023, 
to April 1, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you should not have been kept in the 
facility so long and you should not have to pay 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 a $15 
copayment per day for days 1 to 20, a $75 copayment per day for days 21 to 44, and $0 copayment for days 45 
to 100 for SNF care.  
 You have been asked to pay a $225 copayment for a SNF stay ($15 per day x 15 days = $225). This 
item/service falls within the SNF 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 a 
SNF stay provided from March 17, 2023, to April 1, 2023.