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

 
We decided that the Plan does not have to pre-approve a pontic on tooth #19 and 20 (D6245). 
 
You asked the Plan to pre-approve a pontic. You say that crowns are listed as a covered service in your benefits 
package. The Plan denied your request. The Plan says a pontic (D6245) is not covered by 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 pre-approve a 
pontic on tooth #19 and 20 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the amalgam - three surfaces, primary or permanent (D2160) 
provided March 1, 2022. 
 
You asked the Plan to pay for the amalgam. You say that you were sent misleading information that indicated 
your dental charges would be covered up to $2,000. The Plan denied your request. The Plan says this service is 
not covered under your 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 the 
amalgam - three surfaces, primary or permanent (D2160) provided March 1, 2022.  
 
Your complaint about potentially receiving inaccurate or misleading information from the Plan is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the air ambulance transportation provided on July 8, 2021. 
 
You asked the Plan to pay for the transportation. The Plan denied your request. The Plan says this is included 
in the hospital payment. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance transportation is covered as an 
inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a covered SNF service 
and payment is made under Part A for that service.  Because the service is covered and payable as a beneficiary 
transportation service under Part A, the service cannot be classified and paid for as an ambulance service under 
Part B. 
 
We looked at the file and Medicare rules. The records show that the enrollee was an inpatient when the 
ambulance services were provided. Payment for the services is included in the inpatient payment, and separate 
payment cannot be made. Based on this information, we decided that Medicare rules for coverage of the transportation have not been met. Therefore, we decided that the Plan does not have to pay for the air 
ambulance transportation provided on July 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crown filling for tooth #2 (D2950) provided on March 23, 2022. 
 
You asked the Plan to pay for the crown filling for tooth #2. 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 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 crown 
filling for tooth #2 (D2950) provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary and mandibular denture (D5110 
and D5120) provided by a participating provider. 
 
You asked the Plan to pre-approve a complete maxillary and mandibular denture. You say that the enrollee's 
dentures are worn down and are no longer functional. The Plan denied your request. The Plan says the 
requested dentures 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 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 
complete maxillary and mandibular denture (D5110 and D5120) provided by a participating provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says IRF care is not medically necessary and the enrollee's needs can be met at a lower 
level of care such as in a skilled nursing facility or at home with home health services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that while the enrollee may benefit from continued physical therapy and occupational therapy, her rehab needs can be safely provided in a lower intensity and alternate setting such as in a skilled 
nursing facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation feature (E2300) and attendant 
control (E2331). 
 
You asked the Plan to pre-approve the power wheelchair accessories. You say that this equipment for a power 
wheelchair is medically reasonable and necessary. The Plan denied your request. The Plan says the rules for 
coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that power seat elevation feature (E2300) is non-
covered because it is not primarily medical in nature Medicare rules say that if an attendant control (E2331) is 
provided in addition to a beneficiary-operated drive control system, it will be denied as non-covered. 
 
 We looked at the file and Medicare rules. In this case, the power seat elevation feature is statutorily non-
covered. In addition, since the Plan has already approved coverage for a beneficiary-operated drive control 
system, the attendant control requested will not be covered. Based on this information, we decided that 
Medicare rules for coverage of the power wheelchair accessories have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the power seat elevation feature (E2300) and attendant control (E2331).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the power seat elevation system (E2300). 
 
You asked the Plan to pre-approve the power seat elevation system. You say that you need the elevation to be 
able to transfer in and out of bed or else you will not be able to get out of the chair. The Plan denied your 
request. The Plan says this is a convenience item and is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the power seat elevation system have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the power seat elevation system (E2300).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for re-evaluation - limited oral evaluation (D0170) provided by a 
participating provider on February 28, 2022. 
 
You asked the Plan to pay for re-evaluation - limited oral evaluation. You say that you were never told that 
certain services were not covered. The Plan denied your request. The Plan says D0170 is not a covered dental 
benefit. 
 
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 re-
evaluation - limited oral evaluation (D0170) provided by a participating provider on February 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial maxillary denture (D5225). 
 
You asked the Plan to pre-approve the denture. You say that you disagree with the denial for dental services. 
The Plan denied your request. The Plan says this service is covered by your dental benefits; however, your 
benefit for one partial maxillary denture every five years has 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. The Plan covers one partial 
maxillary denture every five years. 
 
We looked at this case file, the Plans rules, and Medicare rules. The record shows the Plan paid for a partial 
maxillary denture provided on October 4, 2018; therefore, the benefit for partial maxillary dentures has been 
exhausted. Therefore, we decided that the Plan does not have to pre-approve a partial maxillary denture 
(D5225).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewing x-rays (D0274), periodic oral evaluation (D0120), 
and prophylaxis (D1110) provided on April 22, 2021, and a periodic oral evaluation (D0120) and prophylaxis 
(D1110) provided on October 28, 2021. 
 
You asked the Plan to pay for x-rays, evaluations, and prophylaxis. You say that you have seen this dentist for 
over 15 years and that you have always been reimbursed. The Plan denied your request. The Plan says this 
provider has opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for bitewing 
x-rays (D0274), periodic oral evaluation (D0120), and prophylaxis (D1110) provided on April 22, 2021, and a 
periodic oral evaluation (D0120) and prophylaxis (D1110) provided on October 28, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the coinsurance for the office visit  
 
You asked the Plan to waive the coinsurance for an office visit office visit. You say that you are confused about 
how and why you owe for the office visit.  The Plan denied your request. The Plan says that the coinsurance 
amount was applied correctly.  
 
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 incorrect Evidence of Coverage was submitted. This means that 
we cannot determine the cost you are being asked to pay is correct or justified by the Plan contract. It is the 
burden of the Health Plan to substantiate their decision with evidence. In this case, the decision has not been 
substantiated so we must find in your favor. Therefore, we decided that the Plan has to waive the coinsurance 
for an office visit   
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a telehealth visit provided on August 4, 2021. 
 
You asked the Plan to pay for the telehealth visit. The Plan denied your request. The Plan says telehealth is 
covered only in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the enrollee must use a network provider who offers the service by telehealth. 
 
 The requested provider in this case is not a network provider with the Plan for telehealth services. The Plan did 
not pre-approve the services at issue. We found no exception that would require the Plan to pay for these 
services. Therefore, we decided that the Plan does not have to pay for a telehealth visit provided on 
August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 17, 
2021. 
 
You asked the Plan to pay for the services provided. You say that the enrollee was seen twice on the same date 
by two different providers. The Plan denied your request. The Plan says the documentation does not indicate 
that the emergency visits were performed for unrelated issues. 
 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 99282 is a column II code to column I code 99283. 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 the emergency room 
services provided on December 17, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency room services provided on December 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that this encounter was not work-related. The 
Plan denied your request. The Plan says the cost is the responsibility of the liability carrier. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible for the services 
provided until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan 
does not have to pay for the emergency room services provided on December 8, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Qulipta 30mg tablet medication. 
 
You asked the Plan to pre-approve this medication. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says this medication is not a covered benefit under the 
enrollees contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve the Qulipta 30mg tablet 
medication.  
 Benefits for this medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for tendon injections performed on June 22, 
2020, and September 27, 2021. 
 
You asked the Plan to waive the copayments for the injections. You say that you do not understand why the 
two charges are different for the same procedure. The Plan denied your request. The Plan says you have been 
charged the correct cost sharing 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 a $300 
copayment for surgery or services provided at a location other than an ambulatory surgical center.  
 
You have been asked to pay $121.36 for the injection provided on June 22, 2020, and $48.29 for the injection 
provided on September 27, 2021, both of which are less than the $300 copayment for the injections. The 
injections fall within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities and 
Ambulatory Surgical Centers 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 copayments for tendon 
injections performed on June 22, 2020, and September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve an expandable control system. We decided that the Plan does not 
have to pre-approve a power seat elevation system.  
 
You asked the Plan to pre-approve the requested services. The Plan says that you can control the approved 
power options using their own switches. 
 
We decided that the Plan has to pre-approve an expandable control system.  
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that an expandable control system was requested, identified by codes E2377, E2313, and 
E2311. 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 requested services. Our physician 
reviewer found that you have a past medical history of post-polio syndrome and bilateral carpal tunnel 
syndrome, status post surgical release. A group 3 power wheelchair with power elevating leg rests, power tilt, 
and recline with expandable control system was approved. Your bilateral carpal tunnel syndrome has resulted 
in impaired upper limb strength documented in clinical information and the group 3 power wheelchair has 3 
power functions thus an expandable controller is medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the requested services have been met. Therefore, we decided that the Plan has to 
pre-approve an expandable control system.  
 
We also decided that the Plan does not have to pre-approve a power seat elevation system. 
 
The Plan follows Medicare rules. Medicare rules say that wheelchair options and accessories are only covered 
under certain medical indications.  
 
The file shows that a power seat elevation system was requested. We looked at the file, and Medicare rules. 
This item is not primarily medical in nature and not covered. Based on this information, we decided that 
Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-
approve a power seat elevation system. 
 
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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on 
March 11, 2022. 
 
You asked the Plan to waive the copayment for the ER visit. You say that you needed a catheter inserted and it 
should have been done during surgery the day prior. The Plan denied your request. The Plan says you have 
been charged the correct cost sharing 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 a $90 
copayment per visit for emergency care.  
 
You have been asked to pay a $90 copayment for the ER visit. The ER visit falls within the Emergency 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. 
Therefore, we decided that the Plan does not have to waive the copayment for an emergency room (ER) visit 
provided on March 11, 2022.