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

 
We decided that the Plan does not have to pay additionally for the dental services (D7310) provided on August 31, 2021. 
 
You asked the Plan to pay additionally for the dental services. You say that you would like the Plan to 
reconsider your request. The Plan denied your request. The Plan says the services have processed correctly per 
your supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
In this case, you received dental services on July 26, 2021, and August 31, 2021. The file shows that the Plan 
has paid the maximum allowed amount of $2000 for your dental services. Anything over this amount is your 
responsibility. The Plan reprocessed the claim for the August 31, 2021, date of service to apply your 
coinsurance for codes D5140 and D7210 correctly. Your total responsibility for all of the dental services 
provided on August 31, 2021, is $4077.40. Therefore, we decided that the Plan does not have to pay 
additionally for the dental services (D7310) provided on August 31, 2021.
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. The Plan denied your request. The Plan says IRF admission 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 complexity of the enrollee's nursing, medical and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not support that the enrollee requires at least 3 hours a day /5 days a week, or 15 hours 
over 7 consecutive days, of therapy services. It is not clear 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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - 3/4 porcelain/ceramic (D2783) provided on 
November 11, 2021. 
 
You asked the Plan to pay for dental code D2783. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says dental code D2783 is not covered under the 
Plan's supplemental dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, dental code D2783 is not among those 
covered under this benefit. Therefore, we decided that the Plan does not have to pay for the crown - 3/4 
porcelain/ceramic (D2783) provided on November 11, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement of the copayment for the laryngoscopy, 
flexible; diagnostic (31575) provided on September 10, 2021. 
 
You asked the Plan to issue reimbursement. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to 
the service provided. 
 
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 $250 
copayment for Medicare-covered surgery or other services provided to you at an outpatient hospital, including 
but not limited to hospital or other facility charges and physician or surgical charges.     
You have been asked to pay $169.81 for the Medicare-covered surgery provided at an outpatient hospital. This 
is the Plans allowed amount for this service which is less than the applicable copayment. 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 issue reimbursement of the copayment for the laryngoscopy, flexible; diagnostic (31575) 
provided on September 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ophthalmology visit provided on 
October 19, 2021. 
 
You asked the Plan to waive the copayment for specialist visit. You say that this charge exceeds the allowable 
and you cannot be balance billed. The Plan denied your request. The Plan says the copayment amount you are 
being charged is 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 $40 
copayment for each in-network covered specialist visit. 
 
You have been asked to pay $40 copayment for specialist visit. Specialist visit falls within the 
Physician/Practitioner Services, Including Doctor's Office Visits 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 ophthalmology visit provided on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit, cystourethroscopy, and urinalysis to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve an office visit, cystourethroscopy, and urinalysis. You say that this provider 
has knowledge of your history of symptoms and treatment for over 5 years. YOu also say that you have been 
experiences issues with urinal bleeding, prostate enlargements, testicles inflammation and needs treatment as 
soon as possible. The Plan denied your request. The Plan says this provider is not currently contracted with the 
Plan, and there is a network provider who is available to treat your condition. 
 
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, cystourethroscopy, and urinalysis to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a diagnostic colonoscopy provided on 
October 28, 2021. 
 
You asked the Plan to waive the copayment for diagnostic colonoscopy. You say that this is listed as a 
preventive service under your contract so you should not be responsible for a copayment. The Plan denied your 
request. The Plan says the copayment amount you are being charged is correct. The Plan also says that they 
have reduced the copayment amount for this claim from $350 to $275. 
 
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 $275 
copayment for diagnostic colonoscopy provided at an ambulatory surgical center. The record shows that this 
colonoscopy was provided due to a non-routine diagnosis, so it is considered to be a surgical service and not a 
preventive service.  You have been asked to pay $275 copayment for diagnostic colonoscopy. Diagnostic colonoscopy falls within 
the Outpatient Hospital 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 a 
diagnostic colonoscopy provided on October 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for arthrocentesis services provided on August 
13, 2021. 
 
You asked the Plan to waive the copayment for the arthrocentesis services. You say that the services should be 
covered as you have already paid the $40 copayment for physician services. The Plan denied your request. The 
Plan says the cost-sharing applied correctly based on the services provided. 
 
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 $250 
copayment for Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory 
surgical centers.  
 
 
 You have been asked to pay a $229.94 copayment for arthrocentesis services, which is less than the $250 stated 
in the Plans contract. Arthrocentesis services 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 copayment for arthrocentesis services provided on August 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services you provided to the enrollee on August 25, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you forgot to submit an authorization request 
to the Plan for this visit, but you would like retro authorization. The Plan denied your request. The Plan says 
unauthorized, non-plan care is not covered. 
 
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. 
 
You are 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 medical services you provided to the enrollee on August 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve services to be provided by an out-of-network oral 
surgeon. 
 
You asked the Plan to pre-approve out-of-network dental care. You say that these services are necessary, and 
you would like to have them performed at this facility. The Plan denied your request. The Plan says out-of-
network dental care is not covered by your benefit. There are in-network providers available who can provide 
the necessary services. 
 
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 says that dental 
services are only covered when received by a participating provider. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, out-of-network items or services are 
not among those covered under this benefit. The Plan has in-network providers available to provide the 
necessary care. Therefore, we decided that the Plan does not have to pre-approve services to be provided by an 
out-of-network oral surgeon.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on February 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says there is no established relationship with the ordering provider.
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.
We looked at the file and Medicare rules. The submitted documentation does not contain medical records from non-contract provider. Without records, it cannot be confirmed that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services provided on February 8, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay additionally for the dental services (D5750, D5751, and D1999) 
provided on October 20, 2021. 
 
You asked the Plan to pay additionally for dental codes D5750, D5751, and D1999. You say that you would 
like the Plan to reconsider your request. The Plan denied your request. The Plan says per the supplemental 
dental benefit, dental code D5751 reline complete mandibular denture which shares frequency with dental code 
D5750 is covered once every calendar year at 100%. The benefit was exhausted on the same claim at issue on 
date of service October 20, 2021. Dental code D1999 is not a covered code under the Plan's supplemental 
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. 
 
We looked at the file, the Plan's rules, and Medicare rules. In this case, per the Plan's supplemental dental 
benefit, dental code D5751 reline complete mandibular denture which shares frequency with dental code D5750 is covered once every calendar year at 100%. The benefit was exhausted on the same claim at issue on 
date of service October 20, 2021, as the Plan paid for dental code D5750. Dental code D1999 is not a covered 
code under the Plan's supplemental dental benefit. Therefore, we decided that the Plan does not have to pay 
additionally for the dental services (D5750, D5751, and D1999) provided on October 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a panoramic x-ray (D0330), and cone beam computed 
tomography (CT) (D0365, D0366, D0367). 
 
You asked the Plan to pre-approve the dental services. You say that the CT scans are needed to determine the 
quantity and quality of bone for dental implant placement. You also say that the requested services are 
medically necessary. The Plan denied your request. The Plan says 1 panoramic x-ray is covered every 36 
months. The Plan says 1 cone beam CT capture is covered every 6 months. The Plan also says that these 
frequency limits have been exceeded. 
 
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 and the requested services are listed as 
covered, the frequency limits have been reached. The record shows that the Plan paid for a panoramic x-ray 
and cone beam CT that you received on November 15, 2021. Therefore, we decided that the Plan does not have 
to pre-approve a panoramic x-ray (D0330), and cone beam computed tomography (CT) (D0365, D0366, D0367).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from 
April 16, 2020, to April 20, 2020. 
 
You asked the Plan to waive the copayment for the inpatient hospital services. You say that the services were a 
year and a half old and you were not an orthopedic patient. 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 $375 per 
day for days 1-5 and $0 per day after day 5 for each inpatient stay.  
 
The file shows that you were in the hospital from April 16, 2020, to April 20, 2020. Therefore, you have been 
asked to pay $375 per day for the first four days of inpatient hospital services. The total for your stay is $1,500 ($375 copayment x 4 days = $1,500). The inpatient hospital services fall within the Inpatient Hospital 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 inpatient hospital services 
provided from April 16, 2020, to April 20, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110). 
 
You asked the Plan to pre-approve the dental item. You say that the requested denture is medically necessary. 
The Plan denied your request. The Plan says complete upper denture is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested complete upper denture 
is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-
approve a complete upper denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing of four or more 
teeth per quadrant (D4341) for all four quadrants. 
 
You asked the Plan to pre-approve periodontal scaling and root planing. You say that that you need these deep 
cleaning services, and your gums are hurting. The Plan denied your request. The Plan says the criteria for 
medical necessity for periodontal scaling and root planing services are not met in this case. Your tooth must 
have noticeable bone loss or show that there is a hard substance built up on the roots of your teeth. Your x-rays 
do not show that you have these issues. 
 
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. The Plan covers periodontal 
scaling and root planing 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 and root planing. 
Our reviewer says that the requested services are not medically necessary in this case. Our physician reviewer 
found that the provided radiographs reveal no loss of attachment as evidenced by the lack of any loss of 
supporting bone around any of the teeth in the upper and lower arches.  Periodontal disease is an affliction of the supporting structures of the teeth where there is a loss of clinical attachment around one or more teeth, seen radiographically as a loss of bone support. The bone levels seen in the supplied x-rays are approximately 100% with no clinical loss of support. The supplied periodontal charting indicates multiple sites in all quadrants of pockets in excess of 3mm, up to 6 mm depth. In this case, although there are multiple sites on the periodontal chart that show greater than 3 mm pocketing, the lack of any 
apparent loss of bone indicates that the pockets are caused by a gingival condition and not periodontitis. Root 
surfaces are hidden from the oral environment in a healthy attachment system. If the root surfaces are not 
exposed by the loss of bone support, then they cannot be scaled and planed. Given the records provided, it 
appears there has been no loss of attachment and the requested periodontal scalings are not appropriately 
submitted for the situation as it presents, namely a gingival condition. There is no medical necessity for the 
requested procedures. 
 
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 and root planing have not been met. Therefore, we decided 
that the Plan does not have to pre-approve periodontal scaling and root planing of four or more teeth per 
quadrant (D4341) for all four quadrants.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency care provided on October 7, 
2021. 
 
You asked the Plan to waive the copayment for emergency care. You say that you had to return to have stitches 
removed and should only owe a $30 copayment. The Plan denied your request. The Plan says the claims were 
processed correctly and you are being charged the correct amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $90 
copayment for emergency care.  
 
 
 
 
 
 
 You have been asked to pay a $90 copayment for emergency care. Emergency care 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 emergency care provided on 
October 7, 2021.