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

We decided that the Plan does not have to pay for the preventive procedure and complete series of intraoral x-
rays provided on June 10, 2020. 
 
You asked the Plan to pay for the preventive procedure and complete series of intraoral x-rays. You say that the 
provider assured you that the most you would pay for the services you received would be a total of $22.00. The 
Plan denied your request. The Plan says these services are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
preventive procedure and complete series of intraoral x-rays provided on June 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve extractions of tooth #'s 21 and 26. 
 
You asked the Plan to pre-approve the two extractions. You say that you need these teeth extracted before you 
can get new dentures. The Plan denied your request. The Plan says your benefit provides coverage for 1 
extraction per calendar year. The Plan also says that your extractions benefit has been exhausted for the 2020 
plan year. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, non-surgical or surgical extractions are 
limited to one procedure per calendar year. The record shows that you were approved for an extraction of tooth 
#20 on September 30, 2020, and your extractions benefit has been exhausted. Therefore, we decided that the 
Plan does not have to pre-approve extractions of tooth #'s 21 and 26.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom artificial breast prosthesis. 
 
You asked the Plan to pre-approve the prosthesis. You say that over the counter prosthetics have been 
uncomfortable over the years. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the medical necessity for the additional features 
of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been 
established.  
 
A custom prosthesis cannot be covered in this case. Based on this information, we decided that Medicare rules 
for coverage of the prosthesis have not been met. Therefore, we decided that the Plan does not have to pre-
approve a custom artificial breast prosthesis.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to reimburse you more money for the specialist services provided from 
February 26, 2020, to May 20, 2020. 
 
You asked the Plan to reimburse you more money for the specialist services. You say that the Plan owes you 
more money. The Plan denied your request. The Plan says you were reimbursed correctly with the $40 
copayments applied. 
 
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 $40 
copayment for Outpatient Mental Health Care.  
 
You have been asked to pay a $40 copayment for the specialist services. The specialist services fall within the 
Outpatient Mental Health Care 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. The Plan has reimbursed you the Medicare allowed amounts minus the 
copayments. Therefore, we decided that the Plan does not have to reimburse you an additional amount of 
money for the specialist services provided from February 26, 2020, to May 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services you received on May 30, 2020. 
 
You asked the Plan to pay for the dental services. You say that you called to add the dental rider. The Plan 
denied your request. The Plan says your dental rider was not active until June 1, 2020. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. The Plan?s supplemental dental rider was not active on the date of service in question. 
Therefore, we decided that the Plan does not have to pay for the dental services you received on May 30, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture sectioning (D9120) provided on 
August 6, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have been having issues with your mouth. 
You say that you have seen many doctors. You say that you have been prescribed medication multiple times. 
You also say that you have been in pain for over 5 months. The Plan denied your request. The Plan says fixed 
partial denture sectioning is not listed as 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 Plan?s 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. Additionally, the Evidence of Coverage clearly states that any services 
not listed are not covered. Therefore, we decided that the Plan does not have to pay for the fixed partial denture 
sectioning (D9120) provided on August 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided from 
April 2, 2019, to November 21, 2019. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. You say that you disagree with the 
additional charges and cannot afford them. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You received Medicare Part B drugs on April 2, 2019. The total allowed amount is $1,125 and 20% of that is 
$125.  
 
You received Medicare Part B drugs on August 6, 2019. The total allowed amount is $599.25 and 20% of that 
is $119.85. 
 
You received Medicare Part B drugs on November 21, 2019. The total allowed amount is $599.25 and 20% of 
that is $119.85. 
 
The total amount you owe is: $584.55. 
 
You have been asked to pay the total coinsurance amount of $584.55 for Medicare Part B drugs. Medicare Part 
B drugs fall within the Medicare Part B prescription 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 Medicare Part B drugs provided from April 2, 2019, to November 21, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fixed partial denture repair necessitated by restorative 
material failure provided August 12, 2020. 
 
You asked the Plan to pay for this service. You say that this should be covered. The Plan denied your request. 
The Plan says that this 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 Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed 
partial denture repair necessitated by restorative material failure provided August 12, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on June 23, 2020. 
 
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that you received an 
evaluation, and were referred to a periodontist. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided on June 12, 2020 by an out of 
network (OON) provider. 
 
You asked the Plan to pay for lab test. You say that it is clearly the Plan's responsibility to pay this claim. The 
Plan denied your request. The Plan says the denial of payment for this service is correct, because this provider 
is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan. 
 
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 has network providers 
available who can provide 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 the medical services provided on June 12, 2020 by 
an out of network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says your request exceeds the 
allowable routine transportation 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 24 one-way trips per year.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
We looked at your request, the records in the case file, and the rules. 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 routine transportation.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the core buildup. You say that a crown and buildup should be sufficient to 
preserve the remaining structure of tooth #13. The Plan denied your request. The Plan says this service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 pre-approve a 
core buildup, including any pins when required (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180) provided 
on January 21, 2020. 
 
You asked the Plan to pay for the dental service. You say that you have a dental benefit limit of $2,000. You 
also say that you have received care from this dentist in the past and some coverage was provided. The Plan 
denied your request. The Plan says comprehensive periodontal evaluation is not listed as 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the comprehensive periodontal 
evaluation is not among those covered under this benefit. Additionally, the Evidence of Coverage clearly states 
that any services not listed are not covered. Therefore, we decided that the Plan does not have to pay for the 
comprehensive periodontal evaluation (D0180) provided on January 21, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial upper denture (D5213). 
 
You asked the Plan to pre-approve the dental item. You say that your previous denture did not fit properly. You 
also say that your dentist would not fix the issue. The Plan denied your request. The Plan says 1 upper denture 
is covered every 5 calendar years. The Plan also says that the frequency limit has been reached. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the frequency limit of 1 denture every 
5 plan years has been reached. The record shows that the plan paid for an upper denture that you received on 
June 19, 2017. Therefore, we decided that the Plan does not have to pre-approve a partial upper denture 
(D5213).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the repair, complex, eyelids, nose, ears and/or lips services 
coded 13152 and the repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet 
services coded 13132 provided on April 2, 2020. 
 
You asked the Plan to pay for the repair, complex, eyelids, nose, ears and/or lips services and the repair, 
complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet services. You say that you 
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed 
are not supported by the documentation. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 13152 and 13132 are not supported in the medical record. Specifically, the 
documentation submitted does not support that repair, complex, eyelids, nose, ears and/or lips; 2.6 cm to 7.5 
cm was performed. In addition, the documentation submitted does not indicate that repair, complex, forehead, 
cheeks, chin, mouth, neck, axillae, genitalia, hands and/or feet; 2.6 cm to 7.5 cm was performed. There are 
other procedure codes that would be more appropriate for the services provided. 
Based on this information, we decided that Medicare rules for coverage of the repair, complex, eyelids, nose, 
ears and/or lips services and the repair, complex, forehead, cheeks, chin, mouth, neck, axillae, genitalia, hands 
and/or feet services have not been met. Therefore, we decided that the Plan does not have to pay for the repair, 
complex, eyelids, nose, ears and/or lips services coded 13152 and the repair, complex, forehead, cheeks, chin, 
mouth, neck, axillae, genitalia, hands and/or feet services coded 13132 provided on April 2, 2020.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the physical therapy services rendered on January 16, 2020. 
 
You asked the Plan to pay for these services. You say that the services should be covered. The Plan denied 
your request. The Plan says that the allowed amount for therapy was reached. 
 
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 states that the allowed amount has been reached for therapy. While 
there is a Medicare therapy cap, the services may be allowed if medically necessary. The Plan has not provided 
any medical records to show that the services were not medically necessary and eligible for the therapy cap. 
Therefore, we decided that the Plan has to pay for the physical therapy services rendered on January 16, 2020.  
 
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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveadditional power options for a wheelchair for the enrollee.You asked the Planto pre-approvethe accessories. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not medically necessary.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 the accessories. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the documentation does not reveal that the enrollee requires other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) or non-proportional input devices (e.g., sip and puff, head array, etc.) The enrollee does not need to operate 3 or more powered seating actuators through the drive control, a separate display (i.e., for alternate control devices),other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control), or an attendant control. The enrollee's upper extremity strength and function with independence in eating are sufficient for the enrollee to control any power options through their own individual switches.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the accessories have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadditional power options for a wheelchair for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing. 
 
You asked the Plan to pre-approve genetic testing. You say that you would like the plan to reconsider their 
denial The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is only covered for certain indications. 
 
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 genetic testing. Our reviewer says that 
the documentation does not support that the requested genetic testing is medically reasonable or necessary. Our 
physician reviewer found you have a family history of malignant neoplasm of breast. The requested genetic 
testing is considered medically necessary for enrollees with a current diagnosis or a personal history of a cancer 
associated with the BRCA mutation who meets one or more of the criteria found in the most recent version of 
the NCCN guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian or other evidence based 
guideline addressing genetic testing, and the results will be used to benefit the individual tested in terms of 
potential to guide therapeutic decision making. You do not have a current diagnosis or a personal history of 
cancer. Therefore, you do not meet criteria for the requested services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genetic testing have not been met. Therefore, we decided that the Plan does not 
have to pre-approve genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to an out-of-network mental health provider. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the requested services are available in the plan's 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 
a referral to an out-of-network mental health provider.