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

 
We decided that the Plan does not have to pay for gingival irrigation services (D4921) provided on January 11, 
2023, to January 12, 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 gingival 
irrigation services (D4921) provided on January 11, 2023, to January 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0367) provided on December 8, 2022. 
 
You asked the Plan to pay for cone beam CT. 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 cone 
beam CT (D0367) provided on December 8, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit provided on August 8, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says the facility must be enrolled to participate in the 
Medicare program.  
 The Plan must follow Medicare rules. Medicare rules say that Medicare covers services in an emergency 
department only if the emergency clinic is affiliated with a hospital. 
 
We looked at the file and Medicare rules. The file shows that this provider is not affiliated with a hospital and 
is not CMS approved. Based on this information, we decided that Medicare rules for coverage of the 
emergency department visit have not been met. Therefore, we decided that the Plan does not have to pay for an 
emergency department visit provided on August 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics, heel lift. 
 
You asked the Plan to pre-approve foot orthotics. You say that you would like reconsideration because the foot 
orthotics aremedically necessary. 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 pre-approve foot orthotics, heel lift.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fixed denture sectioning (D9120) provided on January 19, 
2023. 
 
You asked the Plan to pay for fixed denture sectioning. 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 fixed 
denture sectioning (D9120) provided on January 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam (D0380) provided on March 6, 2023. 
 
You asked the Plan to pay for the dental service. You say that you were in extreme pain and the procedure was 
necessary to see if you would need a root canal done. The Plan denied your request. The Plan says the denial of 
payment for this service is correct, because the cone beam 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 a cone 
beam (D0380) provided on March 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the hearing aids purchased on January 18, 
2023. 
 
You asked the Plan to issue reimbursement for these items. You say that you are requesting a reconsideration 
of the Plan's denial for payment. The Plan denied your request. The Plan says the hearing aids are not payable 
as they were not purchased from the Plan's select hearing aid provider.  
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when purchased from the Plans select hearing aid provider.  
 
We looked at this case file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of these items have not been met. Specifically, the Plans contract provides coverage for hearing aids 
only when purchased from the Plans select hearing aid provider. However, the hearing aids in this case were 
not purchased from the Plans select hearing aid provider. Therefore, we decided that the Plan does not have to 
issue reimbursement for the hearing aids purchased on January 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the deductible for the oxygen concentrator provided from 
January 1, 2023, to January 7, 2023. 
 
You asked the Plan to reduce the deductible for the oxygen concentrator. You say that you were expecting a 
discount to be applied before the deductible. 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 $150 deductible which applies to in-network durable medical 
equipment and related supplies. Your contract with the Plan also says that you must pay 5% coinsurance after 
meeting the deductible for in-network oxygen equipment. 
 The item or service you asked the Plan to reduce the deductible for falls within the durable medical equipment 
and related supplies benefit category. The Plan has followed Medicare rules by clearly disclosing in the 
contract that there is a $150 deductible which applies to in-network durable medical equipment and related 
supplies. This cost sharing is a contractual obligation that had not been met at the time the oxygen concentrator 
was received on January 1, 2023, to January 7, 2023. Therefore, we decided that the Plan does not have to 
reduce the deductible for the oxygen concentrator provided from January 1, 2023, to January 7, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injections on November 23, 2022. 
 
You asked the Plan to waive the coinsurance for injections. You say that you were under the impression that it 
was covered in full. 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 20% 
coinsurance for Medicare Part B non-chemotherapy prescription drugs. These drugs are covered under Part B 
of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs 
include drugs that usually arent self-administered by the patient and are injected or infused while you are 
getting physician, hospital outpatient, or ambulatory surgical center services. The provider billed in the amount 
of $3,961.14 and the allowed amount is $1,350.60. $1,350.60 x 20% = $270.12. Therefore, results in the total 
cost sharing amount of $270.12. You have been asked to pay a 20% coinsurance for injections. This item/service falls within the Medicare Part 
B prescriptions drugs 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 injections 
on November 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete upper denture (D5110) and a complete lower 
denture (D5120) provided by an out-of-network provider on October 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that you have sent in the dental statements and 
would like the Plan to cover the dental services. 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 a complete upper denture (D5110) and a complete lower denture (D5120) provided by an out-of-
network provider on October 24, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (37232) provided on May 27, 2022. 
 
You asked the Plan to pay for the surgical services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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, the CPT Code Manual definition of code 37232 is open or percutaneous endovascular 
revascularization, of a unilateral tibial/peroneal artery, for each additional vessel, with transluminal 
angioplasty.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the surgical services. Our reviewer says that the records do not support the code billed. Our reviewer found the medical records provided do not include sufficient 
documentation that this procedure was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan 
does not have to pay for surgical services (37232) provided on May 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete reline mandibular denture (D5751) provided on 
January 26, 2023. 
 
You asked the Plan to pay for the dental services. You say that you do not understand why the covered one, but 
not both. 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 one reline complete denture was exhausted on date of service January 26, 2023 with one maxillary reline complete denture. Therefore, we decided that the Plan does not have to pay for a complete 
reline mandibular denture (D5751) provided on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation, cone beam CT scan, filling, 
and application of desensitizing resin for cervical and/or root surface (D2391, D0367, D9911, D0150) provided 
on January 25, 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. Coverage for the application of desensitizing resin for cervical and/or root surface denied 
correctly as they do not fall within your dental benefits. 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 25, 2023. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation, cone beam CT 
scan, filling, and application of desensitizing resin for cervical and/or root surface (D2391, D0367, D9911, 
D0150) provided on January 25, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided on September 12, 2022, by an 
out-of-network (OON) provider.  
 
You asked the Plan to pay for home health services. You say that you are requesting reconsideration asking to 
review the supporting documents. The Plan denied your request. The Plan says the enrollee must receive their 
care from a network provider (for more information about this, see Section 2 of Chapter 3). In most cases, care 
the enrollee receives from an out-of-network provider (a provider who is not part of the plans network) will 
not be 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for home health services provided on September 12, 
2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction (D7210) provided on January 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were never told to go to a participating 
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 an extraction (D7210) provided on January 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation - established patient 
(D0120), and prophylaxis - adult (D1110) provided on February 13, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were unaware the provider was out of 
network, and also that the provider would be allowed to balance bill for the remaining amounts. 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 - established 
patient (D0120), and prophylaxis - adult (D1110) provided on February 13, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation mileage 
(A0100). 
 
You asked the Plan to pre-approve the additional non-emergency transportation mileage. You say that you need 
this service for your oncologist appointments to undergo tests for the disease you suffer from.  You also say that you do not have enough economic resources to pay for a private transportation service. 
The Plan denied your request. The Plan says the requested transportation was for 130 miles, and therefore 
exceeds the limit of the supplemental benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 48 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve additional 
routine mileage for your oncologist appointments. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve additional non-emergency transportation mileage (A0100).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve limited bilateral noninvasive physiologic studies to be 
provided by an out-of-network (OON) provider.  
 
You asked the Plan to pre-approve limited bilateral noninvasive physiologic studies. You say that the services 
should be covered. The Plan denied your request. The Plan says this is available in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
limited bilateral noninvasive physiologic studies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone replacement graft for ridge preservation-per site 
for tooth number 12 (D7953), an alveoloplasty in conjunction with extractions-four or more teeth or tooth 
spaces, per quadrant (D7310 x 2), and an oroantral fistula closure (D7260). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested services are not covered under the 
supplemental dental policy.  
 
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 pre-approve a bone 
replacement graft for ridge preservation-per site for tooth number 12 (D7953), an alveoloplasty in conjunction 
with extractions-four or more teeth or tooth spaces, per quadrant (D7310 x 2), and an oroantral fistula closure 
(D7260).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
provided on October 21, 2022, by an out-of-network (OON) provider.  
 
You asked the Plan to pay for the ophthalmic diagnostic imaging. You say that this service was medically 
necessary. The Plan denied your request. The Plan says enrollees must receive their care from a network 
provider. 
 
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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the item/service at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for this item/service. Therefore, 
we decided that the Plan does not have to pay for the scanning computerized ophthalmic diagnostic imaging 
provided on October 21, 2022, by an out-of-network (OON) provider.