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

 
We decided that the Plan does not have to pre-approve a crown (D2740) to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve a crown. You say that you need this so you can have your smile back. The 
Plan denied your request. The Plan says D2740 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
crown (D2740) to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oral exam, cleaning, and bitewing x-rays to be 
provided by an out of network provider. 
 
You asked the Plan to pre-approve the dental service. You say that you have been seeing this dentist for over 50 
years. You say that you would like to pay for the services out of pocket and be reimbursed by the dental plan. 
You also say that you do not want to change dentists. The Plan denied your request. The Plan says dental 
services provided out of network 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 Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services to be 
provided out of network are not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pre-approve an oral exam, cleaning, and bitewing x-rays to be provided by an out of network 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental surgery procedure (41899) and anesthesia for 
intraoral procedures (00170). 
 
You asked the Plan to pre-approve the dental surgery procedure and anesthesia. You say that these services are 
medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee needs this 
procedure for replacement of missing teeth. The Plan also says that the enrollee does not have supplemental 
benefit for these specific dental services. 
 
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 pre-approve a 
dental surgery procedure (41899) and anesthesia for intraoral procedures (00170).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided from April 8, 2021, to October 23, 
2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
covered. 
 
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 find that CPT code S9123 has a Status Indicator of I on the Physician Fee Schedule. This means that CPT 
code S9123 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
services provided from April 8, 2021, to October 23, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve computed tomography (CT) of the chest for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the records did not include a detailed history showing why this study is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
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 scan. Our reviewer says that the 
requested scan is medically reasonable and necessary. Our physician reviewer found the pulmonary nodule 
described previously is not specific but no follow-up scan is in the records. Additionally, the enrollee has 
restrictive lung disease shown by a pulmonary function test (PFT), and has a history of shortness of breath with 
atypical chest pain. The enrollee is at risk for multiple disease processed, and by PFT alone should qualify for 
the CT scan of the chest. 
 
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 scan have been met. Therefore, we decided that the Plan has to pre-approve 
computed tomography (CT) of the chest for the enrollee.  
 
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: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for a comprehensive eye exam and eye 
refraction provided on December 15, 2021. 
 
You asked the Plan to pay an additional amount for a comprehensive eye exam and eye refraction. The Plan 
denied your request. The Plan says the eye exam was covered at maximum of $75.00. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum allowance of $75.00 
for these services. Therefore, we decided that the Plan does not have to pay an additional amount for a 
comprehensive eye exam and eye refraction provided on December 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for facet joint injections provided on September 23, 2021. 
 
You asked the Plan to pay for facet joint injections. The Plan denied your request. The Plan says that the Plan 
requires utilization of network providers when possible and available and requires authorization for certain 
services. No medical necessity for an out-of-network provider such as an urgent or an emergent situation that 
has been documented. 
 
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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for facet joint injections provided on September 23, 2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says that the requested admission to a SNF does not meet 
criteria. 
 
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 
service is medically necessary. Our physician reviewer found the enrollee does not have documented skilled 
nursing needs. The enrollee does have documented skilled therapy needs. While the enrollee does not require a 
lot of assistance to mobilize, the enrollee does require strength and endurance training. Daily skilled services 
are required to establish a maintenance program or to prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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 pre-approve an endosteal implant (D6010) to be provided by a 
participating provider. 
 
You asked the Plan to pre-approve an endosteal implant. You say that your dentures are causing you pain and 
bleeding. The Plan denied your request. The Plan says D6010 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 an 
endosteal implant (D6010) to be provided by a contracted provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve therapeutic facet joint injections (64493, 64494) for the 
enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that records do not show why the enrollee is not a candidate for 
radiofrequency ablation. 
 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The records do not 
show why the enrollee is not a candidate for radiofrequency ablation. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve therapeutic facet joint injections (64493, 64494) for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete series of intraoral x-rays (D0210) to be 
provided by an endodontist. 
 
You asked the Plan to pre-approve the complete series of intraoral x-rays. You say that you were referred to an 
endodontist specialist to evaluate the issue of the jawbone pain. You also say that this specialist will be the one 
to determine what is going on and how to resolve the issue. The Plan denied your request. The Plan says the 
supplemental dental services benefit of your contract only provides coverage for dental services when 
performed by a participating general dentist. The Plan also says that dental services performed by an 
endodontist 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 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 
covered when they are received by anyone other than a participating general dentist. Therefore, we decided that 
the Plan does not have to pre-approve a complete series of intraoral x-rays (D0210) to be provided by an 
endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction of tooth roots (D7250) provided on October 7, 
2021, dental fillings (D2391, D2330, D2331) provided on November 10, 2021, and the temporary lower 
denture (D5821) provided on November 24, 2021. 
 
You asked the Plan to pay for the dental services. You say that these services are necessary and due to a 
decrease in your income it is difficult to pay for this necessary care. The Plan denied your request. The Plan 
says these services are not covered by your dental benefit. 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
extraction of tooth roots (D7250) provided on October 7, 2021, dental fillings (D2391, D2330, D2331) 
provided on November 10, 2021, and the temporary lower denture (D5821) provided on November 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve temporary dentures to be provided by a participating 
provider. 
 
You asked the Plan to pre-approve temporary dentures. You say that you do not want to wait 8 months for your 
dentures. The Plan denied your request. The Plan says temporary dentures are not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 
temporary dentures to be provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for gingival irrigation (D4921) provided by a contracted 
provider on January 13, 2021. 
 
You asked the Plan to pay for gingival irrigation. You say that you were told you were entitled to a deep 
cleaning. The Plan denied your request. The Plan says D4921 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
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 gingival 
irrigation (D4921) provided by a contracted provider on January 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, erupted tooth or exposed root (elevation 
and/or forceps removal) (D7140) provided October 26, 2021. 
 
You asked the Plan to pay for the tooth extraction. You say that you would like this covered. The Plan denied 
your request. The Plan says this service is excluded from coverage and the provider indicated that they do not 
accept any insurance. 
 
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 extraction, 
erupted tooth or exposed root (elevation and/or forceps removal) (D7140) provided October 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the lab services a bone density (DXA) scan 
provided on December 20, 2021. 
 
You asked the Plan to waive the copayment for the lab services the DXA scan. You say that the service was 
preventative and should be covered. 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 $200 
copayment for diagnostic bone scans.  
You have been asked to pay $24.94, which is less than the $200 copayment for the DXA scan. The DXA 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 the lab services a bone density (DXA) scan provided on 
December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and surgical 
extraction (D7210). 
 
You asked the Plan to pre-approve the dental services. You say that your tooth is rotten and causing severe 
pain. You say that it needs to be extracted. You say that you are afraid you will end up in the hospital because 
of this. You also say that your glucose levels are high as a result. The Plan denied your request. The Plan says 
dental services to be performed by an oral surgeon are not covered. The Plan also says that dental services must 
be performed by a participating general dentist. 
 
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 dental services to be 
performed by an oral surgeon are not covered under this benefit. Therefore, we decided that the Plan does not 
have to pre-approve a comprehensive oral evaluation (D0150) and surgical extraction (D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110), a comprehensive oral evaluation 
(D0150), and an intraoral imaging (D0220) provided by a participating provider on December 16, 2021. 
 
You asked the Plan to pay for prophylaxis, a comprehensive oral evaluation, and an intraoral imaging. You say 
that you feel like this should all be covered. The Plan denied your request. The Plan says D1110 and D0150 has 
already been met and exhausted. The Plan says that D0220 is not a covered dental benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers prophylaxis, a 
comprehensive oral evaluation, and an intraoral imaging when the services are medically necessary and 
reasonable.  
 
We looked at the file and Medicare rules. Evidence was provided to show that D1110 was provided on March 
2, 2021, and July 6, 2021. D0150 was provided on February 27, 2020. D0220 is not a covered dental benefit 
Based on this information, we decided that the Plan's rules for coverage of prophylaxis, a comprehensive oral 
evaluation, and an intraoral imaging have not been met. Therefore, we decided that the Plan does not have to 
pay for prophylaxis (D1110), a comprehensive oral evaluation (D0150), and an intraoral imaging (D0220) 
provided by a participating provider on December 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an extraction (D7210), and a comprehensive oral 
evaluation (D0150) to be provided by an oral surgeon. 
 
You asked the Plan to pre-approve an extraction and a comprehensive oral evaluation. You say that you have a 
cracked tooth, and you need it extracted. The Plan denied your request. The Plan says services must be 
provided by a general dentist. 
 
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 an extraction 
and a comprehensive oral evaluation when the services are medically necessary and reasonable.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an extraction and a comprehensive oral evaluation have not been met. Therefore, we decided that 
the Plan does not have to pre-approve an extraction (D7210), and a comprehensive oral evaluation (D0150) to 
be provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the pelvis 
without and with contrast for the enrollee. 
 
You asked the Plan to pre-approve the MRI. You say that this is medically necessary. The Plan denied your 
request. The Plan says there are no plans for a MR/US (magnetic resonance/ultrasound) fusion biopsy. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
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 MRI. Our reviewer says that the 
requested MRI is not medically reasonable or necessary. Our physician reviewer found without an ultrasound 
fused study, the request for the repeat MRI would not be useful. The fact that the patient has a rising prostate 
specific antigen (PSA) means prostate cancer is possible. A repeat MRI would only be of use if targeted 
ultrasound biopsy would be possible. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the pelvis without and with contrast for the enrollee.