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

 
We decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 21, 22, 23, 
27, 28, double abutments tooth #s 21 and 22 (D6740), and pontic - porcelain/ceramic tooth #'s 24, 25, 26 
(D6245). 
 
You asked the Plan to pre-approve the dental services represented by codes D6740 and D6245. You say that 
you have not seen the dentist in a few months. You also say that you need work done on your teeth. The Plan 
denied your request. The Plan says criteria has not been met for coverage.  
 
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 the dental 
services represented by codes D6740 and D6245 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 the dental services represented by codes 
D6740 and D6245. Our reviewer says that the documentation provided does not meet the criteria for coverage 
for a fixed bridge replacing teeth #'s 24, 25, and 26 using teeth #'s 23, 27 and 28 as abutment retainers.  Our 
physician reviewer found the documentation indicates that there are failing dental implants is areas #24 and 25 
and tooth #28 appears non-restorable. There also appear to be additional mandibular posterior teeth missing 
(#18). A fixed bridge replacing teeth #'s 24, 25 and 26 is not medically reasonable due to the poor bone support 
and condition of the abutments. Other methods of tooth replacement should be considered. 
 
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 the dental services represented by codes D6740 and D6245 have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a retainer crown - porcelain/ceramic tooth #'s 
21, 22, 23, 27, 28, double abutments tooth #s 21 and 22 (D6740), and pontic - porcelain/ceramic tooth #'s 24, 
25, 26 (D6245).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning (D0120, 
D1110) provided on November 1, 2022, to November 9, 2022. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. The $100 deductible also applied correctly based on your contract with 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for a periodic oral evaluation and cleaning 
(D0120, D1110) provided on November 1, 2022, to November 9, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided from 
October 23, 2022, to October 25, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital stay. You say that the Plan should cover 
everything when people are in the hospital with COVID-19. The Plan denied your request. The Plan says this 
cost sharing was charged 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 $300 
copayment for each inpatient hospital stay.  
 
You have been asked to pay a $300 copayment for the inpatient hospital stay. This item/service 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 copayment for the inpatient 
hospital stay provided from October 23, 2022, to October 25, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the outpatient hospital visits provided 
from February 14, 2022, to January 17, 2023 
 
You asked the Plan to waive the copayments for the outpatient hospital visits. You say that you should have no 
copay. The Plan denied your request. The Plan says this cost sharing was charged 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 $10 
copayment for in-network outpatient hospital services.  You have been asked to pay a $10 copayment for each outpatient hospital visit provided on February 14, 2022, 
and August 15, 2022. These items/services fall within the outpatient hospital services benefit category. You 
have also been asked to pay a $10 copayment for the outpatient hospital visit provided on January 17, 2023. 
This item/service falls within the outpatient surgery, including services provided at hospital outpatient facilities 
benefit category. You have been asked to pay a total of $30 ($10 copayment x 3 visits = $30). 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 outpatient hospital visits provided from February 14, 2022, to 
January 17, 2023
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the robotic assisted sacrocolpopexy 
provided on December 12, 2022. 
 
You asked the Plan to waive the cost share for the robotic assisted sacrocolpopexy. You say that you are 
questioning where this charge is coming from. The Plan denied your request. The Plan says this cost sharing 
was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan clearly says that there is a $750 deductible which applies to outpatient surgery. Your 
contract with the Plan also clearly says that there is a $125 copayment for each outpatient surgery. 
 
The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 deductible which 
applies to outpatient surgery. You have been asked to pay $639.99 towards your deductible. This cost sharing is a contractual obligation that had not been met at the time the outpatient surgery was received on December 
12, 2022.  
 
The medical records provided support the services billed, and you are responsible for the cost share amount. 
You have also been asked to pay a $125 copayment for the robotic assisted sacrocolpopexy. You have been 
asked to pay total of $764.99 ($639.99 deductible + $125 copayment = $764.99). This item/service falls within 
the outpatient surgery 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 cost share for the 
outpatient surgery provided on December 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the infusion catheter and pump supplies 
provided on June 3, 2022, and September 6, 2022. 
 
You asked the Plan to waive the coinsurance for the infusion catheter and pump supplies. You say that these 
items should be covered under diabetic supplies. The Plan denied your request. The Plan says this cost sharing 
was charged 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 10% 
coinsurance for in-network durable medical equipment and related supplies.  
 
You have been asked to pay $32.20, which is 10% coinsurance of the allowed amount for each infusion 
catheter ($322.01 allowed amount x 10% coinsurance = $32.20). You have also been asked to pay $9.27, which is 10% coinsurance of the allowed amount for each infusion pump ($97.70 allowed amount x 10% coinsurance 
= $9.27). These items/services fall within the durable medical equipment and related 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 coinsurance for the infusion catheter and pump supplies provided on June 
3, 2022, and September 6, 2022.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to reduce the coinsurance for the infliximab injection provided on February 10, 
2022. 
 
You asked the Plan to reduce the coinsurance for the injection. You say that the intravenous portion of your bill 
is charged wrong. The Plan denied your request. The Plan says that this cost sharing was charged correctly. 
 
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 enrollees must pay 20% coinsurance for Medicare Part B prescription drugs 
obtained in an outpatient setting.  
 
The Plan says you must pay $301.46 for the injection. Based on the Plan contract, however, you cannot be 
asked to pay more than $256.96, which is 20% coinsurance of the allowed amount for the injection ($1,284.81 
allowed amount x 20% = $256.96). Therefore, we decided that the Plan has to reduce the coinsurance for the 
infliximab injection provided on February 10, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to waive the cost share for a magnetic resonance imaging (MRI) provided on July 
21, 2022. 
 
You asked the Plan to waive the cost share for an MRI. You say that you disagree with the cost share The Plan 
denied your request. The Plan says that this cost sharing was charged correctly. 
 
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 enrollees must pay a $0 cost share for outpatient diagnostic tests.  
 
The Plan says you must pay a 20% coinsurance for an MRI. Based on the Plan contract, however, you cannot 
be asked to pay more than a $0 cost share for an MRI. Therefore, we decided that the Plan has to waive the cost 
share for a magnetic resonance imaging (MRI) provided on July 21, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services, pontic, and retainer crown (D6740, 
D2950, D6245) provided on December 5, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for core 
buildup services, pontic, and retainer crown (D6740, D2950, D6245) provided on December 5, 2022.
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. You say that you will benefit from the services to maximize safety 
and independence. The Plan denied your request. The Plan says the services you need can be provided safely in 
another setting such as a skilled nursing facility, home with home health services or home with outpatient 
therapy. 
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical or occupational therapy, there is no documented need for intensive rehabilitation 
services. Medically necessary care can be provided in a different level of care. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sacral nerve stimulation (SNS) (64590). 
 You asked the Plan to pre-approve the sacral nerve stimulation (SNS). You say that the service is medically 
necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that sacral nerve stimulation is covered for the treatment 
of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. 
 
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 sacral nerve stimulation (SNS). Our 
reviewer says that the service is not medically necessary. Our physician reviewer found SNS is not covered in 
patients with neurologic diseases as is the case here (spinal cord injury with neurogenic bladder). 
 
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 sacral nerve stimulation (SNS) have not been met. Therefore, we decided 
that the Plan does not have to pre-approve the sacral nerve stimulation (SNS) (64590).
Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to reduce the copayment for the inpatient stay provided from December 16, 2022, 
to December 17, 2022. We also decided that the Plan does not have to reduce the copayment for the inpatient 
stay provided from December 2, 2022, to December 11, 2022.  
 
You asked the Plan to reduce the copayments for the inpatient hospital stays. You say that you would like these 
charges reduced as you have had several inpatient hospital stays and are on a fixed income. The Plan denied 
your request. The Plan says that this cost sharing was charged correctly. 
 
We decided that the Plan has to reduce the copayment for the inpatient stay provided from December 
16, 2022, to December 17, 2022.  
 
You have been asked to pay a $950 copayment for this inpatient hospital stay. However, the Plan contract says 
that the day before you are discharged is the last inpatient day. The Plan can only ask you to pay a $475 
copayment ($475 copayment per day x 1 day = $475). Therefore, we decided that the Plan has to reduce the 
copayment for the inpatient stay provided from December 16, 2022, to December 17, 2022.  
 
We also decided that the Plan does not have to reduce the copayments for the inpatient stay provided 
from December 2, 2022, to December 11, 2022. 
 
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 $475 
copayment per day for days 1-4 of each inpatient hospital stay.  
 
You have been asked to pay a $475 copayment per day for days 1-4 of the inpatient stay provided from 
December 2, 2022, to December 11, 2022. You have been asked to pay a total of $1,900 for this inpatient 
hospital stay ($475 copayment per day x 4 days = $1,900). This item/service 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 reduce the copayment for the inpatient stay provided from 
December 2, 2022, to December 11, 2022. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
(A0998) provided on December 25, 2021. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that on the date 
of service you began to experience shortness of breath and you were not getting any relief. You say that your 
wife decided to call an ambulance and by the time they arrived, you felt there was no longer a need for 
transport to a hospital emergency room. The Plan denied your request. The Plan says this service is not covered 
under your contract under any normal circumstances. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 
 The ambulance company did not provide transport services on December 25, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport (A0998) provided on December 25, 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. You say that the services are medically necessary for the enrollee 
to be assessed both medically and functionally regarding their premorbid functional capacity to determine 
whether they can benefit from a rehabilitation level of care offered by mentioned facility. The Plan denied your 
request. The Plan says the enrollee's records do not show that they have complex rehabilitation needs that 
require frequent evaluation by a rehab doctor. 
 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 the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the disposable underpads, diapers, and non-sterile 
gloves. 
 
You asked the Plan to pre-approve incontinence supplies. You say that the items are medically necessary. The 
Plan denied your request. The Plan says these are not Medicare covered items. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve the disposable underpads, 
diapers, and non-sterile gloves.