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

 
We decided that the Plan does not have to pay for the extractions (D7140 x 3) provided on July 21, 2021. 
 
You asked the Plan to pay for the dental services. You say that you had no idea that this dentist did not accept 
Medicare. You say that you believe that this is a $300 benefit. You also say that you do not understand why 
you are not able to obtain it. The Plan denied your request. The Plan says the provider in this case has opted out 
of Medicare. The Plan also says that services received by a provider that has opted out of Medicare 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, dental services received by a provider 
that has opted out of Medicare are not among those covered under this benefit. Therefore, we decided that the 
Plan does not have to pay for the extractions (D7140 x 3) provided on July 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation - new or established 
patient (D0150) and full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a 
subsequent visit (D4355) provided November 4, 2021. 
 
You asked the Plan to pay for the comprehensive oral exam and full mouth debridement. You say that your 
dentist had retired during the pandemic, and you needed to see a new dentist. The Plan denied your request. 
The Plan says you have exceeded the frequency limit for the exam and the debridement is not 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 Plan's coverage rules apply in this case. The Plan covers the 
comprehensive oral exam once every 36 months. 
We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive 
exam was previously covered on November 7, 2018. Based on this information, we decided that the Plan's 
frequency limit for coverage of the comprehensive oral exam has been exceeded. Though the Plan offers dental 
benefits in excess of Medicare coverage, the full mouth debridement is not among those covered services. 
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation - new or 
established patient (D0150) and full mouth debridement to enable a comprehensive oral evaluation and 
diagnosis on a subsequent visit (D4355) provided November 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the adjustment of a complete maxillary denture (D5410) and 
adjustment of a complete mandibular denture (D5411) provided on November 2, 2021. 
 
You asked the Plan to pay for the maxillary and mandibular denture adjustments. You say that your dentures 
did not fit properly and caused a great deal of pain. You also say that without the adjustments your dentures are 
essentially useless. The Plan denied your request. The Plan says these services are not covered by your health 
plan or Medicare. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
adjustment of a complete maxillary denture (D5410) and adjustment of a complete mandibular denture 
(D5411) provided on November 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a false tooth for a bridge (D6240) on tooth #19, tooth 
#20, tooth #29, tooth #30 and a white glass with high gold content cap for a bridge (D6750) on tooth #18, tooth 
#21, tooth #28, tooth #31. 
 
You asked the Plan to pre-approve a false tooth for a bridge and a white glass with high gold content cap for a 
bridge. You say that the dentist recommended the crowns and you do not agree with the decision to do partials. 
The Plan denied your request. The Plan says the requested services are not medically necessary. 
 
 
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 a false tooth 
for bridge and a white glass with high gold content cap for bridge 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 a false tooth for bridge and a white 
glass with high gold content cap for bridge. Our reviewer says that the service is not medically necessary. Our 
physician reviewer found that none of the abutment teeth are in need of a crown restoration as there is no noted 
structural damage or caries on those teeth. There are two symmetrical spaces to be restored in the lower arch 
which would be readily amenable to replacement teeth placed on a partial denture. Given the Plan criteria, there 
would be no necessity for the requested bridges on the lower arch. A partial denture would appear to be the 
appliance that would meet the Plan's criteria. 
 
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 a false tooth for bridge and a white glass with high gold content cap for bridge 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a false tooth for a bridge 
(D6240) on tooth #19, tooth #20, tooth #29, tooth #30 and a white glass with high gold content cap for a bridge 
(D6750) on tooth #18, tooth #21, tooth #28, tooth #31.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Esomeprazole Magnesium.
You asked the Plan to pre-approve Esomeprazole Magnesium. You say that this is the only medication that
works for your acid reflux. The Plan denied your request. The Plan says this drug is not eligible for coverage
under the Part B benefit.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Esomeprazole Magnesium.
Benefits for Esomeprazole Magnesium 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IGRT (CPT code 77387), for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the enrollee has not had prior radiation treatment. The Plan states guidelines support 
IGRT in patients with breast cancer during breast boost using photons, during external beam-based accelerated 
partial breast irradiation, during treatment of left breast cancer when a deep inspiration breath hold technique is 
used, and for breast cancer treatment when you are in prone position. The Plan states none of these situations 
were noted. 
 
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 the services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is no documentation of any exceptional circumstances for this 
enrollee. As routine use of IGRT is not within accepted standards or care, our decision is unfavorable. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve IGRT (CPT code 77387), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for home modifications for a dishwasher and the 
delivery/sales tax for the dishwasher, microwave and storm door provided on October 18, 2021. 
 
You asked the Plan to reimburse you for home modifications. The Plan denied your request. The Plan says 
your requested reimbursement for home modification services are not approved services under authorization 
for in-home personal care services. 
 
The Plan contract covers a supplemental SSBCI benefit. The Plan contract says members who meet 
CMS-defined SSBCI eligibility criteria and engage with Plan-sponsored care management, enhanced disease 
management, or similar wellness programs will qualify for a package of potential supplemental benefits.  
We looked at the file and the Plan's rules. The file shows that a dishwasher and delivery/sales tax are not 
covered services. Therefore, we decided that the Plan does not have to reimburse you for home modifications 
for a dishwasher and the delivery/sales tax for the dishwasher, microwave and storm door provided on 
October 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prefabricated abutment (D6056) and implant supported 
porcelain/ceramic crown (D6065) provided on September 20, 2021. 
 
You asked the Plan to pay for the prefabricated abutment and implant supported porcelain/ceramic crown. You 
say that you were specifically told by the Plan that crowns and implants were covered under your dental plan. 
The Plan denied your request. The Plan says these implant services are not covered benefits under your plan. 
The Plan also says that a review of the call indicates you stated that your plan at the time did not cover implants 
which are very expensive, and the Plan representative stated that yes implants are very expensive and are not 
covered through the Plan. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
prefabricated abutment (D6056) and implant supported porcelain/ceramic crown (D6065) provided on September 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies rendered on September 21, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that a status indicator of I represents a code that is not valid 
for Medicare purposes.  
 
We looked at the file and Medicare rules. Billed procedure codes S1015 and S8301 have a status indicator of I 
and are not valid for Medicare purposes. Therefore, we decided that the Plan does not have to pay for the 
supplies rendered on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Aurora Spine ZIP Interspinous Fixation System and 
OsteoAmp Allograft. 
 
You asked the Plan to pre-approve the spinal services. You say that these services are medically reasonable and 
necessary. The Plan denied your request. The Plan says the services requested are considered 
experimental/investigational at this time. 
 
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 the spinal services. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the requested procedures are considered experimental. More research is needed to 
show safety and efficacy of the requested services.  
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 spinal services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve Aurora Spine ZIP Interspinous Fixation System and OsteoAmp Allograft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more 
pathogens are non-covered. 
 
We looked at the file and Medicare rules. The file shows that 6 or more pathogens were tested. Based on this 
information, we decided that Medicare rules for coverage of the laboratory services have not been met. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 24, 
2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on October 
12, 2021. 
 
You asked the Plan to pay for the dental service. You say that it is important to retain your natural teeth. You 
also say that the value they provide long term well being of your personal health. The Plan denied your request. 
The Plan says periodontal maintenance is covered once every 12 months. The Plan also says the frequency 
limit has been exceeded. 
 
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 and periodontal maintenance is covered 
once every 12 months, the frequency limit has been exceeded. The record shows that the Plan paid for 
periodontal maintenance that you received on April 7, 2021. Therefore, we decided that the Plan does not have 
to pay for the periodontal maintenance (D4910) provided on October 12, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composites - four or more surfaces or 
involving incisal angle (anterior) (D2335) provided November 12, 2021. 
 
You asked the Plan to pay for the fillings. You say that you last had fillings in July. The Plan denied your 
request. The Plan says you have exceeded the frequency limit for this service. 
 
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 two fillings 
per calendar year. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that 2 fillings were 
previously covered on August 17, 2021. Based on this information, we decided that the Plan's frequency limit 
for coverage of the fillings has been exceeded. Therefore, we decided that the Plan does not have to pay for the resin-based composites - four or more surfaces or involving incisal angle (anterior) (D2335) provided November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on September 23, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that you have requested to become an in-
network provider and would like for this claim to be paid. The Plan denied your request. The Plan says the 
rendering provider is an out-of-network provider and there was no referral from the enrollee's primary care 
physician. Also, the service rendered was not urgent or emergent in nature. 
 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 September 23, 
2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on October 6, 
2021. 
 
You asked the Plan to waive the copayment for ambulance services. You say that you cannot afford the 
charges. The Plan denied your request. The Plan says the claims were processed correctly and yo 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 $325 
copayment for ambulance services.  
 
You have been asked to pay the allowed amount of $317.82, which is less than the $325 copayment for 
ambulance services. Ambulance services fall within the ambulance 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 ambulance services provided on October 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on November 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for an office visit. You say that services were provided to the enrollee so the claim should be paid. The Plan denied your request. The Plan says the rendering provider is an out-of-network provider with no referral or approved authorization. Also, the services provided was not urgent or emergent.
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 office visit provided on November 23, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injection provided on 
October 22, 2021. 
 
You asked the Plan to waive the coinsurance for the denosumab injection. You say that you were never 
informed there would be coinsurance for this kind of injection. You say that the provider advised there would 
be no coinsurance since this is related to your cancer. The Plan denied your request. The Plan says the 
coinsurance applied 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 20% of 
the cost for Part B drugs.  
 
  You have been asked to pay $508.56, which is 20% of the allowed amount for the denosumab injection. The 
allowed amount is $2,542.80 ($2,542.80 x 20% = $508.56). The denosumab 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 
the denosumab injection provided on October 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional 5 home physical therapy visits. 
 
You asked the Plan to pre-approve an additional 5 home physical therapy visits. You say that the requested 
services are medically necessary. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 an additional 5 home physical therapy 
visits. Our physician reviewer found at this time there are no objective prior physical therapy records to 
determine medical necessity of the additional requested physical therapy visits.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an additional 5 home physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an additional 5 home physical therapy visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient chiropractic office visit (99203) provided 
October 18, 2021. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you are requesting the claim be 
reprocessed showing the correct dates for CPT code 98941. There is a claim for $79 for CPT code 99203 and 
you have not received anything about this claim and you are requesting review. The Plan denied your request. 
The Plan says this service is not covered when rendered by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient chiropractic office visit (99203) provided October 18, 2021.