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

 
We decided that the Plan does not have to pre-approve gingival irrigation in all four quadrants (D4921). 
 
You asked the Plan to pre-approve gingival irrigation. The Plan denied your request. The Plan says gingival 
irrigation (D4921) is not covered by the enrollees 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 
gingival irrigation in all four quadrants (D4921).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance transport provided on January 1, 
2022. 
 
You asked the Plan to waive the copayment for ambulance transport. You say that due to have COVID-19 this 
should be covered. 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 $290 
copayment for in network ambulance services per date of service regardless the number of trips.  
 
You have been asked to pay $290 copayment for ambulance transport. Ambulance transport falls 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 transport 
provided on January 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for a comprehensive eye exam provided on 
January 19, 2022. 
 
You asked the Plan to waive the deductible for the eye exam. You say that you have been covered for these 
services in the past and the provider did not inform you of any charges. The Plan denied your request. The Plan 
says the correct amount was applied to your deductible. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is $290 deductible which applies to certain items and services.  
 
The item or service you asked the Plan to waive the deductible for falls within the Vision Care benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is $290 
deductible which applies to certain items and services. This cost sharing is a contractual obligation that had not 
been met at the time the eye exam was received on January 19, 2022. Therefore, we decided that the Plan does 
not have to waive the deductible for a comprehensive eye exam provided on January 19, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a skin biopsy provided on January 18, 
2022. 
 
You asked the Plan to waive the copayment for a skin biopsy. You say that you feel you should only have a 
$30 copayment. 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 $150 
copayment for Medicare-covered outpatient hospital surgery services. 
 
You have been asked to pay $150 copayment for a skin biopsy.  Skin biopsys fall 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 skin biopsy 
provided on January 18, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve expandable controller, including all related electronics 
and mounting hardware, upgrade provided at initial issue (CPT code E2377), harness for upgrade to 
expandable controller, including all fasteners, connectors and mounting hardware (E2313), electronic 
connection between wheelchair controller and two or more power seating system motors, including all related 
electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311), 
Phone holder (K0108), F3 Hub Cap Color (K0108), and M3 Color Kit Fireball (K0108). 
 
You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your 
request. The Plan says the DME is not necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The Phone holder, Hub Cap Color and Color Kit Fireball do not serve a primary medical purpose. The 
upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not 
medically necessary. They are necessary when there is a medical need to control power options though the 
joystick. The notes do not show a medical need to control the power options through the joystick. The power 
options can be controlled using their own switches. The switches can be made any size without asking for a 
separate request. They can be made from any material without asking for a separate request. All of this can be 
done without the need to use the joystick to control the power features. Therefore, we decided that the Plan 
does not have to pre-approve expandable controller, including all related electronics and mounting hardware, 
upgrade provided at initial issue (CPT code E2377), harness for upgrade to expandable controller, including all 
fasteners, connectors and mounting hardware (E2313), electronic connection between wheelchair controller 
and two or more power seating system motors, including all related electronics, indicator feature, mechanical 
function selection switch, and fixed mounting hardware (E2311), Phone holder (K0108), F3 Hub Cap Color 
(K0108), and M3 Color Kit Fireball (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and a mandibular 
partial denture (D5214). 
 
You asked the Plan to pre-approve the partial denture. You say that you have trouble eating and that your 
current dentures cut your tongue when you eat. The Plan denied your request. The Plan says that you must be 
missing teeth in multiple areas in the mouth in the same arch of the mouth. 
 
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 partial 
dentures 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 partial dentures. Our reviewer says that 
the service is not medically necessary. Our physician reviewer found the upper arch has no remaining teeth and 
would not be eligible for a maxillary partial denture, as a partial denture requires there to be remaining teeth. 
 
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 partial dentures have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a maxillary partial denture (D5213) and a mandibular partial denture (D5214).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, E2311), Q 
logic Joystick (K0108), gel arm pads (K0108) and camera (K0108). 
 
You asked the Plan to pre-approve the requested power wheelchair equipment. You say that this equipment is 
medically reasonable and necessary. The Plan denied your request. The Plan says the criteria for coverage have 
not been met. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose. The rules say that an expandable controller is subject to the criteria listed in the Medicare 
rules section. 
 
The gel arm pads and camera do not serve a purpose that is primarily medical in nature. These items are 
available to the general public and would be helpful even to those who are not sick or injured. 
 
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 for the expandable controller. Our reviewer says that 
the requested expandable controller is not medically reasonable and necessary. Our physician reviewer found 
that in this case the member has a neurologic disorder with functional deficits.  Criteria for a power wheelchair 
are met.  The requested electrical accessories are not medically necessary as the member does have use of the 
upper extremity and can operate and control the power options using the switches that are included in the basic 
wheelchair. As the expandable controller is not necessary, the related joystick will also not be covered. 
 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2377, E2313, 
E2311), Q logic Joystick (K0108), gel arm pads (K0108) and camera (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2750) and a core build-up (D2950), provided by a 
participating provider on February 2, 2022. 
 
You asked the Plan to pay for a crown and a core build-up. You say that you would like the Plan to pay for this. 
You say that this crown was a two-step procedure. The Plan denied your request. The Plan says the rendered 
dental 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a crown 
(D2750) and a core build-up (D2950), provided by a participating provider on February 2, 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 December 
20, 2021. 
 
You asked the Plan to waive the copayment for an urgent care visit. You say that you thought there was no 
charge for this since you saw a physician assistant and not a specialist. 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 $40 
copayment for each urgent care visit.  
 
You have been asked to pay $40 copayment for an urgent care visit.  Urgent care visits fall 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 December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bridge for tooth # 13 and 15 (D6548) and a false-
shaped cap (D6245) on tooth #14. 
 
You asked the Plan to pre-approve bridge and a cap. You say that these dental services are medically 
necessary. The Plan denied your request. The Plan says a bridge for tooth # 13 and 15 (D6548) and a false-
shaped cap (D6245) 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 a 
bridge for tooth # 13 and 15 (D6548) and a false-shaped cap (D6245) on tooth #14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prospective dental services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve prospective dental services. You say that you anticipate needing a dental 
implant in the next several months and you have been using the requested dental provider for 25 years. You say 
you do not want to change providers and ask that the Plan make an exception to approve coverage with the 
requested provider through the end of the contract term. The Plan denied your request. The Plan says the 
requested dental services are available from in-network providers.  There is no evidence you are unable to 
see a provider in-network nor is there any evidence that seeing one in-network would be detrimental to your 
health or inadequately address your needs. The Plan also says that there is no evidence of medical necessity 
that would allow you to see an out-of-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 
prospective dental services to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing services (81206, 81235, 81321) provided 
on July 13, 2021. 
 
You asked the Plan to pay for the genetic testing services. You say that you would like this claim reprocessed 
based no the medical records. The Plan denied your request. The Plan says this claim has not been billed in 
accordance with Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, the services provided should have been billed as a single 
procedural service. Based on this information, we decided that Medicare rules for coverage of the genetic 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for the genetic 
testing services (81206, 81235, 81321) provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit provided on January 21, 
2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you are on a fixed income, and this 
should be covered. 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 $10 
copayment for a primary care provider visit for Medicare-covered services.  
 
You have been asked to pay $10 copayment for an office visit. Office visits fall 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 an office visit provided on January 21, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this inpatient hospital care is 
medically necessary. Plan denied your request. The Plan says there is no medical reason for the enrollee to be 
admitted as an inpatient. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient is an 86-year-old male with knee osteoarthritis. An approved total knee 
arthroplasty procedure was planned. This is a request for inpatient services associated with this procedure. 
However, the provided documentation does not describe the patient currently unstable or with high-risk 
medical history to suggest he would require hospital services that would cross 2 midnights to justify this 
request. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a Facet Injection procedure performed on 
February 22, 2022. 
 
You asked the Plan to waive the copayment an injection. You say that you have had this done before and have 
never had a copayment like this. The Plan denied your request. The Plan says enrollees pay a $200 copayment 
per visit, per provider, per day for surgery performed in an ambulatory surgical center. 
 
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 $200 
copayment for Physician/Practitioner Services, Including Doctor's Office Visits.  
 
 
 
 
 
 You have been asked to pay a $200 copayment for an injection performed on February 22, 2022. An injection 
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 a Facet Injection procedure performed on February 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140) and removals of residual 
tooth roots (D7250) provided on December 22, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the simple extractions and removals of residual tooth roots. You say that these 
services were rendered by an in-network provider. You also say that you received these services for emergency 
reasons. The Plan denied your request. The Plan says services you receive from an OON dentist will not be 
paid for 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 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the simple 
extractions (D7140) and removals of residual tooth roots (D7250) provided on December 22, 2021 by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that you have to visit the clinic every two 
weeks for chemotherapy treatments. You are requesting reconsideration for transportation to the facility. The 
Plan denied your request. The Plan says you are requesting an additional 59 miles for a total of 109 miles and 
your benefit only allows 50 miles. The Plan also says you have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers up to 36 one-way trips and each one-way trip must not exceed 50 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that the Plan's rules for coverage of routine transportation have not been met. Therefore, we decided that the 
Plan does not have to pre-approve additional mileage (A0170).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple extractions (D7140 x 2) and surgical extractions 
(D7210 x 5) provided on December 22, 2021, by the opt-out dentist. 
 
You asked the Plan to pay for the dental services. You say that dental services are not covered by Medicare. 
You also say that you do not understand why it is being denied due to the provider not participating with 
Medicare. The Plan denied your request. The Plan says payment cannot be made for services performed by a 
dentist that has opted out of Medicare. 
 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 extractions are listed as covered, 
the Evidence of Coverage clearly states that if you use a provider that has opted out of Medicare, you will not 
receive reimbursement. Therefore, we decided that the Plan does not have to pay for the simple extractions 
(D7140 x 2) and surgical extractions (D7210 x 5) provided on December 22, 2021, by the opt-out dentist.