Persius/hicric huggingface dataset:
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 April 5, 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 April 5, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye examination and a determination of refractive 
state provided on February 15, 2023.  
You asked the Plan to pay for a routine eye examination and a determination of refractive state. You say that 
prior to the examination, you called the Plan to verify that the provider was in-network. The Plan denied your 
request. The Plan says no calls were found prior to the services being rendered where you were misquoted 
about the provider's network status. The Plan also says that this provider was not in-network. 
 
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 they are obtained through a provider who is in-network with the 
Plan. 
 
We looked at the file and the Plan's rules. The Plan rules say that routine eye examinations and refractions are 
not covered out-of-network. The record shows you saw a provider who is out-of-network. Based on this 
information, we decided that the Plan's rules for coverage for a routine eye examination and a determination of 
refractive state have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye 
examination and a determination of refractive state provided on February 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a core buildup and porcelain crowns provided on March 15, 
2023. 
 
You asked the Plan to pay for a core buildup and porcelain crowns. 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 pay for a core 
buildup and porcelain crowns provided on March 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a myocardial perfusion imaging provided on February 27, 
2023. 
 
You asked the Plan to pay for a myocardial perfusion imaging. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a myocardial perfusion 
imaging provided on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (62323). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when certain requirements are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve an epidural steroid injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the LCD criteria is 
50% improvement for 3 months. This time period has not passed and therefore, the request is deemed not 
medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an epidural steroid injection have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an epidural steroid injection (62323).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete upper denture (D5110) provided on April 28, 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 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 November 30, 2020. 
Therefore, we decided that the Plan does not have to pay for complete upper denture (D5110) provided on 
April 28, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cala trio tremor device (K1018, K1019). 
 
You asked the Plan to pre-approve a Cala trio tremor device. You say that you need a hand tremor device and 
you have not been able to locate one. The Plan denied your request. The Plan says the requested device is 
experimental/investigational. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a Cala trio tremor device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found a Cala Trio tremor stimulator device (K1018) and supplies for use with the device 
(K1019) are not medically necessary per the Social Security Act, Section 1862 (a)1(A) and the 42 CFR 
411.15(k), as Medicare does not pay for any items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. There is 
insufficient evidence in the literature that this device is effective for your condition. The requested K1018 is 
not the standard of care for your tremor according to current guidelines. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a Cala trio tremor device have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Cala trio tremor device (K1018, K1019).
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for the repair or nonroutine service for durable medical equipment (K0739) 
provided on October 3, 2022. 
 
You asked the Plan to pay for the repair or nonroutine service for durable medical equipment. You say that the 
service should be covered. The Plan denied your request. The Plan says that this is a duplicate claim. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did provide any proof the claim was already paid. Therefore, we 
decided that the Plan has to pay for the repair or nonroutine service for durable medical equipment (K0739) 
provided on October 3, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on April 10, 2023. 
 
You asked the Plan to pay for the dental services. You say that you didn't know the provider was not 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 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 April 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on April 11, 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 the services denied correctly as they do not fall 
within your 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 core 
buildup services (D2950) provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a vision item or service (V2799) provided on May 3, 2023.  
You asked the Plan to pay for a vision item or service (V2799). You say that your two requests were for two 
different qualifying benefits as described in the Plan's 2023 summary of benefits. The Plan denied your request. 
The Plan says these frames are not covered as this benefit has already been used for the 2023 calendar year. 
 
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 one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery 
that includes insertion of an intraocular lens. 
 
We looked at the file and the Plan's rules. The Plan rules say that they cover one pair of Medicare-covered 
eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. The record 
shows this benefit has been exhausted. Based on this information, we decided that the Plan's rules for coverage 
of a vision item or service(V2799) have not been met. Therefore, we decided that the Plan does not have to pay 
for a vision item or service (V2799) provided on May 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam computed tomography (CT) scan (D0364) 
provided on May 2, 2023. 
 
You asked the Plan to pay for the cone beam CT scan. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your 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 a cone 
beam computed tomography (CT) scan (D0364) provided on May 2, 2023.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for a CT scan of the head or brain (70470). We decided 
that the Plan does not have to waive the copayment for a CT scan of the neck soft tissue (70492) .  
 You asked the Plan to waive the copayments for CT scans performed on January 12, 2023.. You say that you 
do not agree with the copayment applied and should only be charged for one CT scan copayment. The Plan 
says that this cost sharing was charged correctly. 
We decided that the Plan has to waive the copayment for a CT scan of the head or brain (70470).  
 
The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost sharing information 
(such as copayments, deductibles and coinsurance). The Plan contract does not state in clear terms that there is 
a $75 copayment for each magnetic resonance imaging (MRI), CT, and positron emission tomography (PET) 
scans performed on the same day, during the same visit, by the same provider. Therefore, we decided that the 
Plan has to waive the copayment for a CT scan of the head or brain (70470).  
 
We also decided that the Plan does not have to waive the copayment for a CT scan of the neck soft tissue 
(70492) . 
 
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 $75 
copayment for MRI, CT, and PET scans. Therefore, we decided that the Plan does not have to waive the 
copayment for a CT scan of the neck soft tissue (70492) . 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures and partial mandibular dentures 
(D5110, D5214) provided on March 23, 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 the services denied correctly as they do not fall 
within your 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 complete 
maxillary dentures and partial mandibular dentures (D5110, D5214) provided on March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and 
physician attendance and supervision of hyperbaric oxygen therapy, per session (99183). 
 
You asked the Plan to pre-approve HBO therapy and physician attendance. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that program reimbursement for HBO therapy will be 
limited to that which is administered in a chamber (including the one man unit) and is limited to certain 
conditions. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve HBO therapy and physician attendance. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the 
medical records provided there is no documentation that the hyperbaric oxygen therapy at issue in this case 
meets all Medicare and NCD criteria for medically reasonable and necessary and safe and effective for the 
enrollee. Provided records in this case do not document the enrollee has failed an adequate course of standard 
wound therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO therapy and physician attendance have not been met. Therefore, we 
decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) therapy (G0277) and physician 
attendance and supervision of hyperbaric oxygen therapy, per session (99183).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on February 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 dental services provided on February 15, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on March 22, 
2023. 
 
You asked the Plan to pay for the crown - porcelain/ceramic. You say that the total amount of the crown was 
$1,311 and you have a $1,000 dental coverage so the claim should not have been denied. You also say that the 
provider shows they are in-network so you should have received a discount for using a preferred provider. The 
Plan denied your request. The Plan says your benefit for the requested service $1,000 dollar limit was met. The 
Plan also determined that the provider is not in-network therefore no discount is allowed. 
 
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 date of service March 22, 2023. The records 
show the Plan paid $189 for services provided on March 2, 2023 with $811 remaining in your allowance. The 
total cost of this claim was $1,450 and the plan paid $811 leaving you with a liability of the remaining $639. 
Therefore, we decided that the Plan does not have to pay for a crown - porcelain/ceramic (D2740) provided on 
March 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, D0120) 
provided on April 27, 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 December 06, 2022. 
Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and cleaning (D1110, 
D0120) provided on April 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental prophylaxis (D1110) provided on December 2, 2022.  
 
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 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 July 21, 2022. Therefore, 
we decided that the Plan does not have to pay for dental prophylaxis (D1110) provided on December 2, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
May 2, 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 May 5, 2022. Therefore, 
we decided that the Plan does not have to pay for periodontal scaling and root planing (D4342) provided on 
May 2, 2023.