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

 
We decided that the Plan does not have to pay for the crown (D2740) for tooth number 9 provided on April 14, 
2023. 
 
You asked the Plan to pay for the dental services. You say that it was impossible for you to get decent dental 
services from the in-network providers in your area. After four months with a broken tooth, you went to an out-
of-network provider. The Plan denied your request. The Plan says the dental services were received from an 
out-of-network provider and are not covered by your supplemental benefits. 
 
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 crown (D2740) for tooth number 9 provided on April 14, 2023.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve liver transplant care. 
 
You asked the Plan to pre-approve liver transplant care. You say that the enrollee should remain under the care 
of this transplant program. The Plan denied your request. The Plan says that this provider is not Medicare-
certified for liver transplant. 
 
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 denied authorization for this service solely on the basis that this 
provider is not certified Medicare for liver transplant. However, this provider is certified by Medicare for a 
liver transplant program. The Plan did not provide any other evidence or rationale to support a denial of 
authorization for this service. Therefore, the Plan has not shown that its decision to deny authorization for this 
service is correct or justified. Therefore, we decided that the Plan has to pre-approve liver transplant care.  
 
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 a periodic oral evaluation and cleaning (D0120, D1110) 
provided on September 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 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 January 12, 2023, and 
May 9, 2023. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation and 
cleaning (D0120, D1110) provided on September 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cleaning (D1110) provided on September 26, 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 and feel like the limitations are not clear. The Plan denied your request. The Plan says your 
benefit for the cleanings 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 dental 
cleanings (prophylaxis) was exhausted on date of service(s) January 04, 2023, and May 15, 2023. Therefore, 
we decided that the Plan does not have to pay for a cleaning (D1110) provided on September 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811, 97813, 97814) 
provided from October 11, 2023, to October 18, 2023. 
 
You asked the Plan to pay for the acupuncture services. You say that you are suffering from severe pain on the 
right side of your face due to shingles and the only thing giving you relief is acupuncture. The Plan denied your 
request. The Plan says acupuncture is only covered to treat CLBP. 
 
  The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the services at issue were not used to treat CLBP. 
Therefore, we decided that the Plan does not have to pay for the acupuncture treatments (97810, 97811, 97813, 
97814) provided from October 11, 2023, to October 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the semi-precision abutment-placement (D6191 x2), the 
semi-precision attachment-placement (D6192 x2), the implant/abutment (D6111), and the unspecified 
removable prosthodontic procedure (D5899). 
 
You asked the Plan to pre-approve the semi-precision abutment-placement (D6191 x2), the semi-precision 
attachment-placement (D6192 x2), the implant/abutment (D6111), and the unspecified removable 
prosthodontic procedure (D5899). You say that you are not able to chew your food and your dentures move 
around.  You say this is not a cosmetic procedure and is medically necessary. The Plan denied your request. 
The Plan says the services are not covered 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 semi-precision abutment-placement 
(D6191 x2), the semi-precision attachment-placement (D6192 x2), the implant/abutment (D6111), and the 
unspecified removable prosthodontic procedure (D5899) are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve the semi-precision abutment-placement 
(D6191 x2), the semi-precision attachment-placement (D6192 x2), the implant/abutment (D6111), and the 
unspecified removable prosthodontic procedure (D5899).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 2, 
2023. 
 
You asked the Plan to pay for procedure code 70450. You say that you are requesting the claim be reviewed 
and reprocessed for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled 
into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 2, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341) for 
the lower right quadrant and to pay for the periodontal scaling and root planing (D4341) for the upper left and 
lower left quadrants provided on August 14, 2023, and August 15, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing because the original 
approval showed the dental services only being charged $122 for the services. 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 $102 for dental services on May 24, 2023. On August 14, 2023, the Plan paid $398 for 
dental services. For the year of 2023 the Plan paid $500 for dental services; therefore, your annual dental 
maximum benefit for the year of 2023 was exhausted on the date of service of August 14, 2023. Therefore, we 
decided that the Plan does not have to pay more for the periodontal scaling and root planing (D4341) for the 
lower right quadrant and to pay for the periodontal scaling and root planing (D4341) for the upper left and 
lower left quadrants provided on August 14, 2023, and August 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited oral evaluation - problem focused (D0140), and 
intraoral - periapical first radiographic image (D0220) provided on September 22, 2023. 
 
You asked the Plan to pay for the dental services. You say that this service was needed to get x-rays to have a 
tooth extracted. The Plan denied your request. The Plan says this service is not a covered expense under your 
dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral 
evaluation - problem focused (D0140), and intraoral - periapical first radiographic image (D0220) provided on 
September 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on September 11, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you are requesting a standard appeal of the 
recent denial of your dental claim. 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 8, 2023. Therefore, 
we decided that the Plan does not have to pay for periodontal maintenance (D4910) provided on September 11, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye refraction (92015), an eye examination (92014) and 
glucose, blood by glucose monitoring devices (82962) provided on March 17, 2022. 
 
You asked the Plan to pay for an eye refraction, an eye examination and glucose, blood by glucose monitoring 
devices. You say that after a denial with another Plan, you were informed that the member has other insurance, 
which is this Plan. You also say you have spent a lot of time on this claim, so you would like it reprocessed for 
payment. The Plan denied your request. The Plan says the time limit for filing has expired. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
 
  The record shows that a claim for an eye refraction, an eye examination and glucose, blood by glucose 
monitoring devices was not filed until August 22, 2023. This means that more than one calendar year from the 
date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay 
for an eye refraction (92015), an eye examination (92014) and glucose, blood by glucose monitoring devices 
(82962) provided on March 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an adult prophylaxis (D1110) and periodontal maintenance 
(D4910) provided on September 14, 2023. 
 
You asked the Plan to pay for the dental services. You say that in your case, your dentist specifically 
recommended this treatment four times a year based upon your propensity to accumulate plaque buildup at a 
rate significantly faster than average. 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 June 23, 2023. Therefore, 
we decided that the Plan does not have to pay for an adult prophylaxis (D1110) and periodontal maintenance 
(D4910) provided on September 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit for observation (D9430) provided on August 
1, 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 an office 
visit for observation (D9430) provided on August 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on September 27, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the procedure needed to be redone because you 
could not get your x-rays from your previous provider because they went out of business. 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 09, 2023. 
Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on 
September 27, 2023.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room (ER) Visit (85025, 80053, 93005, 
99285) provided on September 13, 2023. 
 
You asked the Plan to pay for the ER visit. 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 the rendering provider 
is not enrolled with Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
 
  Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for an emergency room (ER) Visit (85025, 
80053, 93005, 99285) provided on September 13, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a continuous glucose monitor (CGM) and related supplies 
provided by an out-of-network provider on July 12, 2023. 
 
You asked the Plan to pay for the CGM and related supplies. You say that you have provided all the required 
documentation 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 a continuous glucose monitor (CGM) and related 
supplies provided by an out-of-network provider on July 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the complete upper denture (D5110) provided on  
June 15, 2023. 
 
You asked the Plan to pay more for the dental item. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the enrollee is responsible for any 
charged amount above the Plans cost-sharing amount when the items/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. 
 
The enrollee has been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation the enrollee agreed to pay when he enrolled in the Plan.   
 
Therefore, we decided that the Plan does not have to pay more for the complete upper denture (D5110) 
provided on June 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98940) rendered by 
the out-of-network (OON) provider on August 25, 2023.  
 
You asked the Plan to pay for this 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 service was rendered by an out-of-network 
provider, without prior authorization. 
  
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan 
does not have to pay for the chiropractic manipulative treatment (98940) rendered by the out-of-network 
(OON) provider on August 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150), and intraoral  comprehensive series of radiographic images (D0210) provided on August 7, 
2023. 
 
You asked the Plan to pay for the dental services. You say that you feel the decision should be reversed 
because the website led you to believe that this provider was in-network. You also say that had you known that 
the dentist would eventually be in-network you would have waited a little longer to get an appointment. 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 comprehensive oral evaluation - new or established patient (D0150), and intraoral  
comprehensive series of radiographic images (D0210) provided on August 7, 2023.