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

 
We decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown. 
 
You asked the Plan to pre-approve a porcelain fused to high noble metal crown. You say that this dental work 
is necessary. The Plan denied your request. The Plan says clinical requirements for coverage have not been 
met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a porcelain 
fused to high noble metal crown when the services are medically necessary and reasonable. The Plan also states 
that for an anterior tooth that four or more surfaces be involved before a crown can be considered 
 
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 porcelain fused to high noble metal crown. Our reviewer says that the requested dental services are not necessary. Our physician reviewer found 
that there is insufficient missing or damaged structure on tooth #7 to consider the need for a full coverage 
crown. There appears to be a reasonable small distal restoration in place and the tooth is otherwise intact.  
There is a request for endodontic treatment which may be necessary but unsubstantiated as there is no clear 
periapical lesion seen on the provided radiograph. The requests also then include a support post and a crown. It 
is noted that anterior teeth that have endodontic treatment do not routinely require posts or crowns, and each 
particular situation must be assessed on its own merits. In this instance there is only a small to moderate sized 
restoration, and no endodontic access as yet. There are at most two involved surfaces at the present time, and 
this would be insufficient to require a full crown, even if there was a reasonably small endodontic access made. 
 
In addition, the Plan requires that for an anterior tooth that four or more surfaces be involved before a crown 
can be considered. In this instance, there would be insufficient missing tooth structure as to qualify for a crown 
under this coverage 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 porcelain fused to high noble metal crown have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a porcelain fused to high noble metal crown.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on February 28, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the rehabilitation service. You say that the service should be covered. You also 
say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization 
was not obtained before the services were provided. 
 
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 provider in this case is not a network provider with the Plan. 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 the therapeutic exercises (97110) provided on February 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup, including any pins (D2950) X 2, retainer crown 
- porcelain/ceramic (D6740) X 2, and pontic - porcelain/ceramic (D6245) X 2 provided on April 25, 2022. 
 
You asked the Plan to pay for the dental services. You say that the amount owed is not what was discussed 
with the provider. 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 April 25, 2022. Therefore, we decided that the Plan does not have to pay for core buildup, including any pins (D2950) X 2, 
retainer crown - porcelain/ceramic (D6740) X 2, and pontic - porcelain/ceramic (D6245) X 2 provided on April 
25, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the therapeutic apheresis services 
(mechanical separation of plasma from blood) provided from March 11, 2022, to March 29, 2022. 
 
You asked the Plan to waive the copayments for the therapeutic apheresis services. You say that these services 
were not provided in a hospital and are not outpatient surgeries. 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 a $100 
copayment for surgery or other services provided to you at an outpatient hospital. The record shows the service 
provided is considered a surgical procedure, and the place of service to be an outpatient facility. 
 You have been asked to pay $600 in copayments for the therapeutic apheresis services. The therapeutic 
apheresis services fall within the 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 copayments for the therapeutic apheresis services (mechanical 
separation of plasma from blood) provided from March 11, 2022, to March 29, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for inpatient hospital care provided from 
April 24, 2021, to May 1, 2021, and from May 13, 2021, to May 15, 2021. 
 
You asked the Plan to waive the copayments for the inpatient care. You say that you do not know why you 
were billed. 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 a $300 
copayment for each inpatient admission, up to a yearly maximum of $900.  
 
You have been asked to pay a $300 copayment for each admission for the inpatient care, for a total of $600. 
The inpatient care falls 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 copayments for inpatient hospital care provided from April 24, 2021, to May 1, 2021, and from 
May 13, 2021, to May 15, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are unable to swallow or communicate at this 
time. The Plan denied your request. The Plan says based on Medicare guidelines the skilled nursing facility 
services you are requesting do not meet the requirements for approval. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found you were at a total assist level with functional mobility and bed bound at baseline. 
You tolerated a diet of minced/moist solids and nectar thickened liquids. You do not have daily skilled nursing 
needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. You do not 
have daily skilled therapy needs that require the specialized skill, knowledge, and judgment of a skilled 
professional therapist. Our reviewer also found that you do not require daily skilled nursing and/or skilled 
therapy on an inpatient basis in a skilled nursing facility (SNF) setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation - problem focused (D0140) 
provided on March 22, 2022. 
 
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for 
the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the 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 March 17, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation - problem focused 
(D0140) provided on March 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injections provided on March 1, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for injections. You say that you would like to request reconsideration for payment. 
The Plan denied your request. The Plan says the provider is out-of-network, and it was determined these 
services can be received in-network. 
 
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 injections provided on March 1, 2022, by an out-
of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a CT scan provided on May 25, 2022. 
 
You asked the Plan to waive the copayment for a CT scan. You say that you had another CT scan previously 
that had no copayment and would like to have the $150 copayment reconsidered. The Plan denied your request. 
The Plan says the copayment applied 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 a $150 
copayment for Medicare-covered diagnostic radiology services (not including x-rays).  
 
You have been asked to pay a $150 copayment for a CT scan. A CT scan falls within the Outpatient Diagnostic 
Tests and Therapeutic Services and Supplies 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 CT scan provided on May 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4342 and D4341) 
provided by an out-of-network provider on May 5, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you believe the Plan should 
pay for this. The Plan denied your request. The Plan says the rendered dental work 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 
periodontal scaling and root planing (D4342 and D4341) provided by an out-of-network provider on May 5, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 18, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that the services should be covered. The Plan 
denied your request. The Plan says services performed by an out-of-network provider are 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. 
 
The provider in this case is not a network provider with the Plan. 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 March 18, 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 bone replacement graft for ridge preservation (CPT 
code D7953) and surgical placement of implant body (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that the dental services are necessary. The Plan 
denied your request. The Plan says the services 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 bone replacement graft 
for ridge preservation (D7953) is not among those covered under this benefit. Furthermore, the enrollee 
received surgical placement of implant body: endosteal implant, tooth # 18, # 19 (D6010), on June 27, 2022. 
Procedure code D6010 is a covered benefit with a limitation of two per 1 calendar year (either D6010 or 
D6013). Therefore, the enrollee exceeded their limit of two per 1 calendar years. Therefore, we decided that the 
Plan does not have to pre-approve bone replacement graft for ridge preservation (CPT code D7953) and 
surgical placement of implant body (D6010).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport provided on August 16, 2021. 
 
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied 
your request. The Plan says Medicare does not cover transportation from one facility to another if not 
medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for ambulance service, basic life support, non-
emergency transport. Our reviewer says that ambulance service, basic life support, non-emergency transport is 
not medically necessary. Our physician reviewer found that the enrollee is an 89-year-old female with joint 
pain and weakness who was transported via ambulance from a skilled nursing facility to a health and 
rehabilitation facility. She was unable to ambulate prior to transportation and was moved on the stretcher for 
transport. The enrollees vitals were stable and exam at baseline/unremarkable. She did not receive any 
treatment during the trip. The documentation does not support that other means of transport (such as stretcher van, wheelchair van) were contraindicated for this patient on August 16, 2021. The documentation does not 
support that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a 
fully equipped ambulance can provide for safe transport on August 16, 2021. The documentation does not 
support that the ambulance transport on August 16, 2021 was medically reasonable and necessary for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of ambulance service, basic life support, non-emergency transport have not been 
met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-
emergency transport provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on September 20, 2021, by 
a chiropractor. 
 
You asked the Plan to pay for the office visit. You say that the provider used to be in network. You say that a 
plan representative advised the provider was in network. You also say that the error was made on the plan's part 
and should be paid. The Plan denied your request. The Plan says the claim processed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it in this case. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the office visit have not been met. Specifically, the file indicates that office visits are not covered 
when provided by a chiropractor. Therefore, we decided that the Plan does not have to pay for the office visit 
(99202) provided on September 20, 2021, by a chiropractor.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you should not have to 
pay this copayment due to the circumstance with which you were injured. The Plan denied your request. The 
Plan says you were charged this cost sharing 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 $175 
copayment for each ambulance trip. You had 1 ambulance trip(s). The Plan charged you $175 for these 
services. 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 the ambulance services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve specialist visit to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve specialist visit. You say that this would be a one-time follow-up 
appointment. The Plan denied your request. The Plan says the service 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 
specialist visit to be provided 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 the office visit provided on May 11, 2022. 
 
 
You asked the Plan to waive the copayment for the office visit. You say that you never have been charged for 
an office visit copay for your yearly exam before. 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 a $30 
copayment per specialist visit.  
 
You have been asked to pay a $30 copayment for the office visit with a specialist. The office visit falls within 
the Physician/Practitioner Services, Including Doctors 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 the office visit provided on May 11, 2022.