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

 
We decided that the Plan does not have to pay more for the application of fluoride varnish (D1206) and to pay 
for a periodic oral evaluation (D0120), the intraoral radiographic images (D0220 and D0230), the bitewings 
(D0274), the 2D photographic images (D0350), and the oral hygiene instructions (D1330) provided on 
September 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing your annual preventive 
care maintenance visit because you have never been charged for the dental services before. 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 $884 for dental services on March 7, 2023. On March 9, 2023, the Plan paid $305 for 
dental services. On April 3, 2023, the Plan paid $1,666 for dental services. On September 6, 2023, the Plan 
paid $145 for dental services. For the year of 2023 the Plan paid $3,000 ($884 paid + $305 paid + $1,666 paid 
+ $145 paid) for dental services; therefore, your annual dental maximum benefit for the year of 2023 was 
exhausted on the date of service of September 6, 2023. Therefore, we decided that the Plan does not have to 
pay more for the application of fluoride varnish (D1206) and to pay for a periodic oral evaluation (D0120), the 
intraoral radiographic images (D0220 and D0230), the bitewings (D0274), the 2D photographic images 
(D0350), and the oral hygiene instructions (D1330) provided on September 6, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supply allowance for a continuous glucose monitor 
(CGM) provided by an out-of-network provider on June 23, 2023. 
 
You asked the Plan to pay for the supply allowance for a CGM. You say that you have submitted all the 
required documents and would like the claim processed. The Plan denied your request. The Plan says the 
documentation requirements have not been met. The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain a valid proof of delivery. Specifically, there is no signed receipt of the delivery. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. 
Therefore, we decided that the Plan does not have to pay for the supply allowance for a continuous glucose 
monitor (CGM) provided by an out-of-network provider on June 23, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from August 17, 2023, to 
August 20, 2023. 
 
You asked the Plan to pay for the inpatient hospital care. You say that you went to the hospital and they 
performed surgery to remove your gallbladder The Plan denied your request. The Plan says the rendered 
services require prior authorization when rendered by an in-network provider.  
 
The Plan contract says prior authorization is required for in-network inpatient hospital care.  
 
We looked at the file and Plans rules. The file shows that the inpatient hospital care was not prior authorized. 
Based on this information, we decided that Plans rules for coverage of the inpatient hospital care have not 
been met. Therefore, we decided that the Plan does not have to pay for inpatient hospital care provided from 
August 17, 2023, to August 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodic comprehensive preventive medicine 
reevaluation and management of an individual (99397) provided on September 29, 2023. 
 
You asked the Plan to pay for the routine physical. You say that you have not had this procedure done this year. 
The Plan denied your request. The Plan says the benefit for this service has been exhausted. 
 
The Plan must follow Medicare rules. The rules say that plans must pay for a medical service or item if regular 
Medicare would pay for it in this case. 
 
Based on review of the file, an annual physical exam was provided less than 12 months prior to the visit at 
issue in this case, thus exhausting the benefit. Therefore, we decided that the Plan does not have to pay for the 
periodic comprehensive preventive medicine reevaluation and management of an individual (99397) provided 
on September 29, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on February 7, 2023, to March 
1, 2023. 
 
You asked the Plan to pay for the dental services. You say that you checked the plan coverage information 
which stated that filings were covered. You also say that you were never told by your dentist that the filing he 
was using for the posterior teeth was not an accepted filling and would be denied for payment. The Plan denied 
your request. The Plan says your benefit for the dental services $1,200 dollar limit was met. 
 
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 services was exhausted on date of service March 1, 2023. Therefore, we 
decided that the Plan does not have to pay for the dental services provided on February 7, 2023, to March 1, 
2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to issue reimbursement for the physical or manipulative therapy performed for 
maintenance rather than restoration (S8990) on September 14, 2023 and September 18, 2023. 
 
You asked the Plan to issue reimbursement 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 that the services 
at issue are not covered by Medicare.  
 
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. Specifically, the Plan has stated that the services at issue are not covered by 
Medicare. However, the Plans contract states that 20 routine chiropractic visits are covered per year. The Plan 
has not provided evidence as to why the services at issue would not be covered under this routine chiropractic 
benefit. The Plan has not substantiated their denial; therefore, we must find in your favor. Therefore, we 
decided that the Plan has to issue reimbursement for the physical or manipulative therapy performed for 
maintenance rather than restoration (S8990) on September 14, 2023 and September 18, 2023.  
 
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: Favorable

 
We decided that the Plan has to pay for a comprehensive oral evaluation (D0150) provided on December 13, 
2022. 
 
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 that your benefit for the requested item or service 
has already been exhausted. 
 
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.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The Plan has 
not made reasonable and diligent efforts to gather and forward to us information regarding their decision to 
deny your request. There is no evidence showing your benefit for the requested item or service was previously 
exhausted. Therefore, we decided that the Plan has to pay for a comprehensive oral evaluation (D0150) 
provided on December 13, 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 comprehensive oral evaluation (D0150) provided on 
September 20, 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 April 19, 2022. 
Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) provided 
on September 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for complete maxillary dentures and mandibular partial denture 
(D5110, D5214) provided on August 15, 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 April 23, 2019. 
Therefore, we decided that the Plan does not have to pay for complete maxillary dentures and mandibular 
partial denture (D5110, D5214) provided on August 15, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics (L3000).  
 
You asked the Plan to pay for the foot orthotics. You say that your leg pain has improved with foot orthotics. 
You also say that you have been going to physical therapy for treatment of left hip tendinitis/bursitis and your 
foot pain has gone from a 10 to a 2 with the orthotics. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pay for foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the limited oral evaluation-problem focused (D0140) 
and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided 
on August 30, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 the limited oral evaluation-problem focused 
(D0140) and the extraction, of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) 
provided on August 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-comprehensive series of radiographic images 
(D0210) provided on July 21, 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 May 12, 2021. Therefore, 
we decided that the Plan does not have to pay for intraoral-comprehensive series of radiographic images (D0210) provided on July 21, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic crown (D2740) and the intraoral-
periapical first radiographic image (D0220) provided on August 16, 2023. 
 
You asked the Plan to pay for the dental item/service. 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 item and service 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 item/service from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, dental items/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 porcelain/ceramic crown (D2740) and the intraoral-periapical first radiographic image (D0220) provided on 
August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 18, 2023, to July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that this was medically necessary. 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 May 18, 2023, to July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D6245 and D6548) on October 9, 2023. 
 
You asked the Plan to pay for the dental services (D6245 and D6548). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service August 28, 2023. 
Therefore, we decided that the Plan does not have to pay for the dental services (D6245 and D6548) on 
October 9, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost share for the amalgam filling on tooth #13 provided 
on September 22, 2023. 
 
You asked the Plan to reduce the cost sharing for a filling. You say that you paid a good portion and you are 
trying to understand if you have this again what should you expect to be paying. You also say that the dentist 
sent another bill for $50 more, and you are disputing that. The Plan denied your request. The Plan says your 
total responsibility for the filling processed correctly in accordance with your plan benefits. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 50% 
coinsurance for a filling after the $100 deductible has been met for Class 2 basic services.  
 The contract also says that fillings covered once every 24 months per surface, per tooth. White fillings on posterior 
teeth will be processed as a silver filling and the patient is responsible for up to the contracted fee.  
 
You have been asked to pay the remaining deductible amount of $199. You pay 50% coinsurance after the 
$100 deductible for Class 2 basic services. The contracted allowed amount is $164 ($164 - $100 (deductible) = 
$64). 50% coinsurance for the service is $32. The difference in the allowed amount ($231 - $164 = $67). 
Therefore your responsibility for the services is $199.00. This service falls within the Class 2 basic 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 reduce the cost share for the amalgam filling on tooth #13 
provided on September 22, 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 (D1110, 
D0120) provided on August 16, 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 denial. 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 
(D1110, D0120) provided on August 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for  the crowns - porcelain/ceramic (D2740) 
provided on July 26, 2023. We also decided that the Plan does not have to pay for core buildup, including any 
pins when required (D2950) provided on July 26, 2023. 
 
You asked the Plan to reduce the copayment for the crowns. You also asked the Plan to pay for the core 
buildup. You say that you were told by the provider to pay $1,500 out-of-pocket and the plan will pay you back 
80%. You also say that you have not been paid and you are not allowed to visit the providers office. The Plan 
denied your request. The Plan says the coinsurance was appropriately applied to the crowns provided. The Plan 
also say that core buildup is not a covered benefit. 
 
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 $20% 
coinsurance for crowns - porcelain/ceramic.  
 
You have been asked to pay a $20% coinsurance for the crowns. This service falls within the dental 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 reduce the copayment for  the crowns - porcelain/ceramic 
(D2740) provided on July 26, 2023.  
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the core buildup is 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 July 26, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent hospital care (99232) provided on October 16, 
2023. 
 
You asked the Plan to pay for subsequent hospital care (99232). You say that you want the Plan to pay for the 
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 subsequent hospital care 
(99232) provided on October 16, 2023.