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

 
We decided that the Plan does not have to pay for an additional tooth for a partial denture (D5650), and 
extractions (D7210), provided on December 2, 2022. 
 
You asked the Plan to pay for D5650 and D7210. You say that you were told after that these services were 
covered. The Plan denied your request. The Plan says these services 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 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 
additional tooth for a partial denture (D5650), and extractions (D7210), provided on December 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the arthrocentesis provided on January 4, 
2023. 
 
You asked the Plan to waive the deductible for the arthrocentesis. You say that you should not have to pay your 
deductible as this service was initiated in December 2022. 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. Your 
contract with the Plan says that there is a $400 deductible which applies to the arthrocentesis. Your contract 
with the Plan says that there is 2% coinsurance of the approved amount, after you meet your annual deductible 
for outpatient hospital services. 
 You have been asked to pay $44.42 towards your deductible for the arthrocentesis. The item or service you 
asked the Plan to waive the deductible for falls within the outpatient hospital services benefit category. The 
Plan has followed Medicare rules by clearly disclosing in the contract that there is a $400 deductible which 
applies to outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the 
time the arthrocentesis was received on January 4, 2023. Therefore, we decided that the Plan does not have to 
waive the deductible for the arthrocentesis provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for scaling with gingival inflammation 
provided on November 28, 2022. 
 
You asked the Plan to waive the coinsurance for scaling with gingival inflammation. 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 20% 
coinsurance for Class 2 Basic Services. 
 
You have been asked to pay $25.40 which is 20% of the allowed amount for scaling with gingival 
inflammation. This item/service falls within the Dental 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 scaling with gingival inflammation provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the guided tissue regeneration (D4266) and bone 
replacement grafts (D7953) for tooth #2 and #3 provided on February 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are appealing the denied dental services. 
The Plan denied your request. The Plan says the denial of payment for these services is correct, because the 
guided tissue regeneration and bone replacement grafts 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 
guided tissue regeneration (D4266) and bone replacement grafts (D7953) for tooth #2 and #3 provided on 
February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft  retained natural tooth  first site 
in quadrant (D4263), invalid procedure code (D0063), and guided tissue regeneration - resorbable barrier, per 
site (D4266) provided on March 9, 2022. 
 
You asked the Plan to pay for the dental services represented by codes D4263, D0063, and D4266. The Plan 
denied your request. The Plan says any dental procedure not mentioned in the EOC document is considered not 
covered. The Plan also say that  your benefit for the bone replacement graft  retained natural tooth  first site 
in quadrant D4263 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, the dental services represented by 
codes D4266 and D0063 are not among those covered under this benefit. The record shows your benefit for the 
bone replacement graft  retained natural tooth  first site in quadrant D4263 was exhausted, as tooth #30 was 
extracted on date of service October 25, 2021. Therefore, we decided that the Plan does not have to pay for a 
bone replacement graft  retained natural tooth  first site in quadrant (D4263), invalid procedure code 
(D0063), and guided tissue regeneration - resorbable barrier, per site (D4266) provided on March 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of implant body (D6010), an implant 
supported fixed denture (D6114), and extractions (D6010) for tooth #2, #3, #4, #6, #7, #10, #11, #13, #14, and 
#15 provided by an out-of-network provider on August 23, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were medically necessary, 
and you would like the Plan to reimburse you the charges. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have 
to pay for the surgical placement of implant body (D6010), an implant supported fixed denture (D6114), and 
extractions (D6010) for tooth #2, #3, #4, #6, #7, #10, #11, #13, #14, and #15 provided by an out-of-network 
provider on August 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the localized delivery of antimicrobial agents (D4381) for 
tooth #19 provided on March 16, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were not aware that you would be charged 
for the injection and should be covered by the Plan. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the localized delivery of antimicrobial agents 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 
localized delivery of antimicrobial agents (D4381) for tooth #19 provided on March 16, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on June 28, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 durable medical equipment (DME) provided on June 28, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the cardioversion provided on October 15, 
2021. 
 
You asked the Plan to waive the copayment for the cardioversion. You say that you were not told of any 
copayment and believe this is fraud. 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 $350 
copayment for outpatient hospital services. 
 
You have been asked to pay a $350 copayment for the cardioversion. 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 the 
cardioversion provided on October 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), oral 
hygiene instructions (D1330), a periodontal maintenance (C4910), and an unspecified adjunctive procedure 
(D9999), provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. The Plan 
denied your request. The Plan says the dental services were received from an out-of-network provider and are 
not covered by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan offers a dental benefit in excess of Medicare coverage, D0120, D0274, D1330 and D4910 are not covered 
under this benefit when received from an out-of-network provider. D9999 is not a covered benefit. Therefore, 
we decided that the Plan does not have to pay for a periodic oral evaluation (D0120), bitewings (D0274), oral 
hygiene instructions (D1330), a periodontal maintenance (C4910), and an unspecified adjunctive procedure 
(D9999), provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on January 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says the dental services were received from an out-of-network provider and are not covered 
by your supplemental benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider.  Therefore, we decided that the Plan does not have 
to pay for dental services provided on January 18, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on January 28, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you went 
to the fire station looking for emergency medical services. You also say that after being checked by both they 
could see you did not need to be transported. 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 January 28, 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 ambulance response and treatment with no 
transport provided on January 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for denosumab injections provided on 
September 21, 2022. 
 
You asked the Plan to waive the coinsurance for the denosumab injections. 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 in-network Medicare Part B prescription drugs.  
 You have been asked to pay 20% coinsurance for the denosumab injections. This item falls within the 
Medicare Part B prescription drugs in-network 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 denosumab injections provided on September 21, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a medical eye exam provided on November 07, 2022. 
 
You asked the Plan to pay for a medical eye exam. You say that you have been seeing this provider every year. 
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 exam 
provided on November 07, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on August 04, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the services should be covered. 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 laboratory services 
provided on August 04, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the pneumatic compression equipment 
provided on November 16, 2022. 
 
You asked the Plan to waive the coinsurance for the pneumatic compression equipment. You say that this was 
prescribed, and you could buy it online without insurance for the same price. 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 in-network durable medical equipment and related supplies. 
 
You have been asked to pay 20% coinsurance for the pneumatic compression equipment. This item/service 
falls within the in-network durable medical equipment and related supplies 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 the pneumatic compression equipment provided on November 16, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a nursing facility visit provided on November 22, 2022. 
 
You asked the Plan to pay for a nursing facility visit. You say that I depend on the facility staff to verify 
eligibility and to obtain 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 a nursing facility visit 
provided on November 22, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on November 19, 2022. 
 
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient information in the record to determine if Medicare rules for coverage of the ambulance services have been met. 
In this case, the date of service at issue is November 19, 2022. However, the records show that the ambulance 
transport was provided on the day of discharge from the hospital to a nursing facility on November 20, 2022. 
The records provided do not support an ambulance transport on November 19, 2022. Therefore, we decided 
that the Plan does not have to pay for the ambulance services provided on November 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), intraoral-periapical images 
(D0220), and a pulp vitality test (D0460) provided on January 25, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the limited oral evaluation and intraoral-periapical images has already 
been exhausted and the pulp vitality test is 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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation and intraoral-periapical images was exhausted on date of service January 3, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation 
(D0140), intraoral-periapical images (D0220), and a pulp vitality test (D0460) provided on January 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete series of radiographic imaging (D0210) provided 
on February 8, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were unaware that was a limit for this 
service. 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 February 3, 2022. Therefore, we decided that the Plan does not have to pay for a complete series of radiographic imaging 
(D0210) provided on February 8, 2023.