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

 
We decided that the Plan does not have to pre-approve crown-porcelain/ceramic (D2740) and core buildup, 
including any pins (D2950) - tooth #14. 
 
You asked the Plan to pre-approve the dental services. You say that you need your crown fixed or replaced 
because the original one was placed incorrectly. 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. Crown-Porcelain/Ceramic 
(D2740) and Core Buildup, including any pins (D2950) are covered benefits with a limitation of one procedure 
per tooth every five plan years. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested crown-porcelain/ceramic (D2740) and core buildup, including any pins 
(D2950) - tooth #14 was exhausted on date of service May 20, 2021. Therefore, we decided that the Plan does 
not have to pre-approve crown-porcelain/ceramic (D2740) and core buildup, including any pins (D2950) - 
tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment on tooth #10 (D6056) and an 
implant supported crown on tooth #10 (D6065). 
 
You asked the Plan to pre-approve the dental services. You say that you would like these services covered. The 
Plan denied your request. The Plan says prefabricated abutments (D6056) and implant supported crowns 
(D6065) are 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 
prefabricated abutment on tooth #10 (D6056) and an implant supported crown on tooth #10 (D6065).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing in all four 
quadrants (D4341). 
 
You asked the Plan to pre-approve periodontal scaling. You say that these services are medically necessary. 
The Plan denied your request. The Plan says these services do not meet the coverage criteria. 
 
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 periodontal 
scaling when the services are medically necessary and reasonable.  
 
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 periodontal scaling. Our reviewer says 
that the coverage criteria has not been met. Our physician reviewer found that the upper right, lower right and 
lower left quadrants appear to have only one or two affected teeth in any one quadrant as evidenced by bone 
loss seen in the supplied x-rays. As the D4341 code is reserved for four or more affected teeth in a quadrant, 
none of the requested quadrants would qualify based on the lack of extensive bone loss. The upper left quadrant has only three teeth remaining, one short of the four-tooth minimum. Given the lack of noticeable bone loss 
around more than two teeth in any or the other quadrants, the plan criteria clearly would not be met for the 
requested codes as there are less than four involved teeth in any quadrant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of periodontal scaling have not been met. Therefore, we decided that the Plan does 
not have to pre-approve periodontal scaling and root planing in all four quadrants (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) provided on May 
5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
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 Plan's 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 14, 2022. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) 
provided on May 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered arm brace. 
 
You asked the Plan to pre-approve a MyoPro powered arm brace. You say that the device is medically 
necessary. The Plan denied your request. The Plan says experimental and investigational procedures are not 
covered by Medicare. 
 
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 a MyoPro powered arm brace. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found there is insufficient literature in the peer reviewed publications to assess 
safety, efficacy, long term outcomes or patient management associated with the use of the MyoPro Orthosis for 
upper extremity paralysis/paresis from conditions such as your brachial plexus injury, or other 
neuromuscular/neurological disease or injury. The requested device is not the standard of care for your 
condition. Therefore, per Social Security Act, Section 1862 (a)1(A) and the 42 CFR 411.15(k), the requested 
orthosis is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the 
functioning of a malformed body member. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a MyoPro powered arm brace have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a MyoPro powered arm brace.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for foot orthotics provided on April 12, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for foot orthotics. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 foot orthotics provided on April 12, 2022, by an 
out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on May 27, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you are appealing the claim payment denial. 
The Plan denied your request. The Plan says the services were provided out-of-network and were not approved 
in advanced. 
 
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 laboratory services provided on May 27, 2022, by 
an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport provided on February 21, 2021. 
 
You asked the Plan to pay for the ambulance transport. You say that this transport was medically necessary due 
to an injury on the patient's leg. The Plan denied your request. The Plan says the ambulance transport was not 
medically necessary. The records show that despite a leg injury, the patient was able to ambulance short 
distances with the aid of an assistive device and was not bed-bound. The patient also did not have any acute 
conditions requiring continuous monitoring. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 pay for the ambulance transport. Our reviewer says 
that the ambulance services were not medically necessary. Our physician reviewer found the patient is a 34-
year-old male for whom ambulance was requested for psychiatric problems. On arrival the patient was found in 
a hospital bed, unable to ambulate due to injury to leg. He was alert and oriented x 3 with stable vitals. He was 
documented to be able to ambulate to the stretcher with assistance. He was transported via stretcher without 
need for treatment or any incident. The documentation does not support that other means of transport (such as 
stretcher van, wheelchair van) were contraindicated for this patient on February 21, 2022. The documentation 
does not support that the patient needed the expertise, services and lifesaving and life-sustaining equipment that only a fully-equipped ambulance can provide for safe transport on February 21, 2022. 
 
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 ambulance transport have not been met. Therefore, we decided that the Plan 
does not have to pay for ambulance transport provided on February 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurances for an injection and radiology services 
provided on May 26, 2022. 
 
You asked the Plan to waive the coinsurances for the injection and radiology services. You say that your 
primary care physician referred you and would like for the services to be covered. 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 out-of-network Medicare Part B and a 50% coinsurance for out-of-network basic radiological 
services.  
  The total amount allowed for the injection was $17.92 with a coinsurance of $3.58 ($17.92 total amount x 20% 
coinsurance). The first total amount allowed for radiology service was $162.93 with a coinsurance of $81.46 
($162.93 total amount x 50% coinsurance). The second allowed amount was $94.77 with a coinsurance of 
$47.38 ($94.77 total amount x 50% coinsurance). The third amount allowed was $39.55 with a coinsurance of 
$19.77 ($39.55 total amount x 50% coinsurance). The last amount allowed was $39.55 with a coinsurance of 
$19.77 ($39.55 total amount x 50% coinsurance). The total amount of coinsurance charges was $171.96 ($3.58 
coinsurance + $81.46 coinsurance + $47.38 coinsurance + $19.77 coinsurance + $19.77 coinsurance). 
 
You have been asked to pay a $3.58 coinsurance for the injection and a $168.38 coinsurance for radiology 
services. This item/service falls within the out-of-network Medicare Part B covered drugs and the out-of-
network basic radiological services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurances for 
an injection and radiology services provided on May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a stair glide. 
 
You asked the Plan to pre-approve a stair glide. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the requested item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they 
are not primarily medical in nature.  
 
While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. 
Therefore, we decided that the Plan does not have to pre-approve a stair glide.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient surgery provided on April 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for outpatient surgery. You say that you are appealing the claim payment denial. The 
Plan denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 outpatient surgery provided on April 26, 2022, by 
an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost sharing for Part B drugs and outpatient diagnostic on 
April 13, 2022. 
 
You asked the Plan to waive the cost sharing for Part B drugs and outpatient diagnostic. You say that you want 
to appeal the amount being charged. 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 each Medicare-covered Part B drug. 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. You must pay a $275 copayment for each Medicare-covered diagnostic 
service. Covered services include but are not limited to diagnostic Imaging (CT scan, MRI/MRA, Myocardial 
Nuclear Perfusion Imaging and PET scans). The provider billed in the amount of $20 and the allowed amount 
is $12. $12 x 20% = $2.40. $2.40 + $275 = $277.40. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and a $275 copayment for outpatient 
diagnostic. This item/service falls 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 cost sharing for Part B drugs and outpatient diagnostic on April 13, 2022.
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 the enrollee needs IRF care. The Plan denied your 
request. The Plan says the enrollee does not meet the Medicare criteria for admission to an IRF. 
 
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 the complexity of the enrollees nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does 
support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-
disciplinary rehabilitation program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an injection provided on June 6, 2022, by an OON provider. 
 
You asked the Plan to pay for an injection. You say to please see the attached primary care physician referral 
along with the medical records to process the claim for payment. The Plan denied your request. The Plan says 
the out-of-network services were not authorized. 
 
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 an injection provided on June 6, 2022, by an OON 
provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary for the 
enrollee. The Plan denied your request. The Plan says criteria for admission to the LTACH have not been met. 
The enrollee's medical needs are being met in the current acute setting. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found transfer to the LTACH is not medically necessary as it would not be clinically 
advantageous at this time. Completion of treatment at the current facility is recommended 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Part B drugs and outpatient hospital 
services on February 23, 2022. 
 
You asked the Plan to waive the coinsurance for Part B drugs and outpatient hospital services. You say that you 
should owe $0. 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 chemotherapy and other drugs covered by Medicare Part B. 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. 
 You must pay a 20% coinsurance for observation room services you get at an outpatient hospital. Observation 
services are hospital outpatient services given to determine if you need to be admitted as an inpatient or can be 
discharged. The provider billed in the amount of $15,000 and the allowed amount is $1,512.25. $1,512.25 x 
20% = $302.45. The provider also billed in the amount of $465 and the allowed amount is $394.12. $394.12 x 
20% = $78.82. $302.45 + $78.82 = $381.27. 
 
You have been asked to pay a 20% coinsurance for Part B drugs and outpatient hospital services. This 
item/service falls within the Medicare Part B prescription drugs and Outpatient hospital observation 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 Part B drugs and outpatient hospital services 
on February 23, 2022.