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

 
We decided that the Plan does not have to pre-approve abutment support porcelain/ceramic crown (D6058), 
facial surgery (D7950), surgical implant placement (D6010) and prefabricated abutment (6056). 
 
You asked the Plan to pre-approve abutment support porcelain/ceramic crown (D6058), facial surgery (D7950), 
surgical implant placement (D6010) and prefabricated abutment (6056). You say that you need this dental 
work. The Plan denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested abutment support 
porcelain/ceramic crown (D6058), facial surgery (D7950), surgical implant placement (D6010) and 
prefabricated abutment (6056) are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pre-approve abutment support porcelain/ceramic crown (D6058), facial surgery (D7950), 
surgical implant placement (D6010) and prefabricated abutment (6056).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #4 and 5 (D6010). 
 
You asked the Plan to pre-approve implants. You say that these services are medically necessary. The Plan 
denied your request. The Plan says dental implants (D6010) 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 
dental implants on tooth #4 and 5 (D6010).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on 
February 15, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. 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 
were non-emergent and prior authorization was not obtained. 
 
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 a domiciliary or rest home visit (99336) provided 
on February 15, 2022 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 complete denture - maxillary (D5110). 
 
You asked the Plan to pre-approve a complete upper denture. You say that your insurance should cover 
dentures. 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 pre-approve a 
complete denture - maxillary (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by a 
periodontist. 
 
You asked the Plan to pre-approve the surgical extraction. You say that the Plan material does not state that an 
extraction will be covered only by a general dentist, and you believe this should be approved for coverage. The 
Plan denied your request. The Plan says your contract only provides coverage for dental services when they are 
performed by a participating general dentist. The Plan also says that dental services performed by a periodontist 
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 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 
covered when they are rendered by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a surgical extraction (D7210) to be provided by a periodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (dental code D6056) and 
porcelain fused to metal crown (dental code D6060) for tooth #4. 
 
You asked the Plan to pre-approve a prefabricated abutment and porcelain fused to metal crown. You say that 
the services requested are needed for your dental health. The Plan denied your request. The Plan says the denial 
of authorization for this service is correct, because a prefabricated abutment and porcelain fused to metal crown 
are not covered by the Plan 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested 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 (dental code D6056) and porcelain fused to metal crown (dental code D6060) for tooth 
#4.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for outpatient therapeutic injections provided 
from November 8, 2021, to November 15, 2021. 
 
You asked the Plan to waive the coinsurance for outpatient therapeutic injections. You say that you should not 
have to pay this coinsurance. The Plan denied your request. The Plan says the coinsurance applied was correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs. The allowed amount of this drug is $847.50 resulting in a 
coinsurance amount of $169.50 ($847.50 x 20% = $169.50). You had two visits, resulting in a total of $339 
($169.50 x 2 = $339).  
 
You have been asked to pay a $339 coinsurance for outpatient therapeutic injections. Outpatient therapeutic 
injections 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 coinsurance for outpatient therapeutic injections 
provided from November 8, 2021, to November 15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) and oral hygiene instructions 
(D1330) provided on March 30, 2022. 
 
You asked the Plan to pay for irrigation and hygiene instructions. You say that these services are part of your 
routine dental cleaning. The Plan denied your request. The Plan says gingival irrigation (D4921) and oral 
hygiene instructions (D1330) 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 pay for gingival 
irrigation (D4921) and oral hygiene instructions (D1330) provided on March 30, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network cardioversion provided on 
March 30, 2022. 
 
You asked the Plan to waive the copayment for a cardioversion. You say that this copayment should be lower. 
The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $375 
copayment for outpatient surgery.  
 
You have been asked to pay a $375 copayment for a cardioversion. A cardioversion falls 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 copayment for an in-network cardioversion provided on March 
30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), 
and bitewing x-rays (D0274) provided on April 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not notified of this policy change. The 
Plan denied your request. The Plan says the dental services were received from an out-of-network provider and 
are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), prophylaxis (D1110), and bitewing x-rays (D0274) provided on 
April 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility services (99308) provided on 
February 9, 2022 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility services. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they were non-emergent and prior authorization was not obtained. 
 
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 subsequent nursing facility services (99308) 
provided on February 9, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a methylprednisolone injection provided 
on March 17, 2022. 
 
You asked the Plan to waive the coinsurance for the injection. You say that you do not remember being 
charged for the injection before. The Plan denied your request. The Plan says the correct coinsurance was 
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 20% 
coinsurance for Part B drugs.  
 
You have been asked to pay $1.14, which is 20% of the allowed amount for the injection ($5.70 allowed 
amount x 20% coinsurance = $1.14). The injection 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 coinsurance for a methylprednisolone injection provided on 
March 17, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications.  
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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has iron deficiency anemia 
with intolerance to oral iron replacement. She has not tried and failed the Plan's required drugs, Infed and 
Venofer. The records do not show that the required drugs would be contraindicated or less effective; therefore, 
Feraheme is not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Feraheme.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided by an out-of-network provider 
on February 22, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you believe the Plan should pay for this. 
The Plan denied your request. The Plan says you are responsible for any charged amount above the Plans cost-
sharing amount when your services are received from an out-of-network provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided by an out-of-
network provider on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an urgent care visit provided on January 30, 
2022. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you should not have a 
copayment for this visit. The Plan denied your request. The Plan says the copayment applied was correct. 
 
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 $50 
copayment for urgently needed services. You have been asked to pay the allowed amount of $24.67, which is 
less than the $50 copayment. 
 
You have been asked to pay a $24.67 copayment for an urgent care visit. An urgent care visit falls within the 
Urgently Needed 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 an urgent 
care visit provided on January 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0365), consultation (D9310), panoramic x-ray (D0330), mandible - closed reduction (D7640), 
and alveoloplasty in conjunction with extractions (D7311) provided on January 26, 2022. 
 
You asked the Plan to pay for the cone beam CT capture and interpretation, consultation, panoramic x-ray, 
mandible - closed reduction, and alveoloplasty. You say that you believe these services should be paid for as a 
medical claim. The Plan denied your request. The Plan says the services provided are all dental services. The 
Plan also says that the annual limit allowed by your dental plan has been paid for this benefit year. 
 
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 Plan pays up to $1,500 every year 
for non-Medicare covered preventive and comprehensive dental services combined. The contract says you are 
responsible for any amount above the dental coverage limit. The record shows that you met the annual 
maximum benefit on April 4, 2022, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the cone beam computed tomography (CT) capture and 
interpretation (D0365), consultation (D9310), panoramic x-ray (D0330), mandible - closed reduction (D7640), 
and alveoloplasty in conjunction with extractions (D7311) provided on January 26, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the pelvis for the 
enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says it is not medically necessary to use this scan of the pelvis to check the liver for this 
indication. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found that the requested scan 
of the pelvis in conjunction with the already approved abdomen is exam is not reasonable. There are no pelvic 
symptoms or findings present. Incidentally, the enrollee had a CT scan of the pelvis on 6/16/22, which showed 
nothing requiring follow-up. 
 
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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve computed tomography (CT) scan of the pelvis for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on April 2, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. 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 were non-emergent and prior authorization was not obtained. 
 
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 subsequent nursing facility care (99309) provided 
on April 2, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for inpatient routine services and items provided to the enrollee March 6, 
2021, to April 29, 2021. 
 
You asked the Plan to pay for the services. You say that these services were provided in good faith. The Plan 
denied your request. The Plan says that several items and services have now identified as routine items and 
services. 
 
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 has not specified why these remaining denied services are still denied. 
The plan has not identified if these services are denied based on coding reasons or medical necessity reasons. It 
is not possible to verify the plan's denial in this case. Therefore, we decided that the Plan has to pay for 
inpatient routine services and items provided to the enrollee March 6, 2021, to April 29, 2021.  
 
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.