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

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration (D4265) provided by a participating provider. 
 
You asked the Plan to pre-approve biologic materials. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the requested dental 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 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 
biologic materials to aid in soft and osseous tissue regeneration (D4265) provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a lower partial denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures because they didn't 
fit, and you thought the replacement would be covered. The Plan denied your request. The Plan says your 
benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service February 5, 2021. 
Therefore, we decided that the Plan does not have to pre-approve a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation (D4921), a prefabricated post and 
core (D2954), and a mandibular partial denture (D5226), provided by a participating provider. 
 
You asked the Plan to pre-approve gingival irrigation, a prefabricated post and core, and a mandibular partial 
denture. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says these 
services have been correctly processed. 
 
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 
gingival irrigation (D4921), a prefabricated post and core (D2954), and a mandibular partial denture (D5226), 
provided by a participating provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to provide an additional 24 trips for doctor appointments. 
 
You asked the Plan to provide additional trips. You say that you are blind and need additional trips for doctor 
appointments. The Plan denied your request. The Plan says extra one-way transportation trips cannot be 
approved. 
  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 40 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 provide an additional 24 trips for doctor appointments.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 93042 billed for date of service June 6, 2021. 
 
You asked the Plan to pay for procedure code 93042. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 93042 is bundled into payment for code 93010. 
 
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 93042 
is a column II code to column I code 93010. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 93042 billed for date of service June 6, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), and primary closure of a sinus perforation (D7261). 
 
You asked the Plan to pre-approve the biologic materials to aid in soft and osseous tissue regeneration, per site 
(D4265), and primary closure of a sinus perforation (D7261). You say that you cannot afford the out-of-pocket 
cost for the bone replacement needed for the dental process to get your dentures. The Plan denied your request. 
The Plan says these services are not covered under the benefit package. 
 
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 
biologic materials to aid in soft and osseous tissue regeneration, per site (D4265), and primary closure of a 
sinus perforation (D7261).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an insertion of a spinal cord stimulator to be provided 
by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve insertion of a spinal cord stimulator. You say that there is only one provider 
qualified to do the procedure. The Plan denied your request. The Plan says there are in-network providers who 
can perform the services. 
 
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 
an insertion of a spinal cord stimulator 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 
tooth #'s 2, 6, 11 and 12 (D7953). 
 
You asked the Plan to pre-approve the bone replacement graft for ridge preservation - per site tooth #'s 2, 6, 11 
and 12 (D7953). You say that you cannot afford the out-of-pocket cost for the bone replacement needed for the 
dental process to get your dentures. The Plan denied your request. The Plan says this service is not covered 
under the benefit package. 
 
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 
bone replacement graft for ridge preservation - per site tooth #'s 2, 6, 11 and 12 (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an occlusal guard  hard appliance, full arch (D9944). 
 
You asked the Plan to pre-approve the occlusal guard  hard appliance, full arch (D9944). You say that you 
need this item to help prevent you from grinding your teeth. The Plan denied your request. The Plan says this 
service is not covered under the benefit package. 
 
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 an 
occlusal guard  hard appliance, full arch (D9944).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Budesonide 3mg capsules. 
 
You asked the Plan to pre-approve Budesonide. You say that Budesonide is medically necessary. The Plan 
denied your request. The Plan says Budesonide is not eligible for coverage under the Part B medical benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Budesonide 3mg capsules.  
 
Benefits for Budesonide 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 21, 2022, to August 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 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 dental 
services on June 21, 2022, to August 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an oral evaluation (D0150) provided on August 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that the provider needed to do an exam before the 
cleaning. 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 the date of service of June 8, 2022. 
Therefore, we decided that the Plan does not have to pay for an oral evaluation (D0150) provided on August 
23, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute 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 that the admission to an IRF is not medically necessary. 
 
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 clinical documentation does not fully specify functional impairments. There 
are no complex functional deficits or active medical comorbidities specified thus the enrollee would not be  
 expected to require intense therapy, or an acute inpatient hospital stay with an interdisciplinary approach to 
rehabilitation care. 
 
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 IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on March 18, 2022. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on March 18, 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 services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 clinical documentation shows that you have functional impairments, but no complex 
functional deficits or active medical comorbidities are specified. Thus, you would not be expected to require intense therapy or an acute hospitalization with an interdisciplinary approach to rehabilitation care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for a medical eye exam provided on 
September 01, 2022. 
 
You asked the Plan to reduce the copayment for a medical eye exam. You say that you feel this copayment 
should be a $20 copay, not a $40. 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 $40 
copayment for vision care. 
 
You have been asked to pay a $40 copayment for a medical eye exam. This item/service falls within the vision 
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 reduce the copayment for a medical eye exam provided on 
September 01, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient hospital visit provided on September 12, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient hospital visit. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollees network primary care physician (PCP) or plan must give 
the enrollee approval in advance before they can use providers not in the plan's network. This is called giving 
them a "referral." 
 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 hospital visit provided on September 
12, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractic visit provided on June 06, 
2022, to June 07, 2022. 
 
You asked the Plan to waive the copayment for chiropractic visit. You say that this should 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 
copayment for Chiropractic services. 
 
You have been asked to pay a $20 copayment for chiropractic visit. This item/service falls within the 
Chiropractic 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 copayment for chiropractic 
visit provided on June 06, 2022, to June 07, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an ear mold/insert (V5265), a hearing aid (V5237), 
conformity evaluation (V5020), and special procedures of the ears/nose/throat, checking two hearing aids 
(92503) provided on September 21, 2022. 
 
You asked the Plan to pay for an ear mold/insert (V5265), a hearing aid (V5237), conformity evaluation 
(V5020), and special procedures of the ears/nose/throat, checking two hearing aids (92503). You say that 
nowhere in the Plan literature did you read an explicit prohibition on reimbursement for rebooting quality 
hearing aids. You also say that you believe reimbursement for audiology services is within reason. The Plan 
denied your request. The Plan says these services are not covered under your contract under any normal 
circumstances. 
 
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 services not covered by Original Medicare. However, the requested services are excluded from this 
benefit.  
 We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of an ear mold/insert (V5265), a hearing aid (V5237), conformity evaluation (V5020), and special 
procedures of the ears/nose/throat, checking two hearing aids (92503) have not been met. Therefore, we 
decided that the Plan does not have to pay for an ear mold/insert (V5265), a hearing aid (V5237), conformity 
evaluation (V5020), and special procedures of the ears/nose/throat, checking two hearing aids (92503) provided 
on September 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial mandibular denture (D5212) provided on July 15, 
2022. 
 
You asked the Plan to pay for the denture. You say that you had to get a tooth pulled, which required you to get 
new dentures. 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 September 1, 2021. 
Therefore, we decided that the Plan does not have to pay for a partial mandibular denture (D5212) provided on 
July 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve office visit. You say that the services are medically necessary. The Plan 
denied your request. The Plan says services can be provided by an in-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 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 
an office visit to be provided by an out-of-network (OON) provider.