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

 
We decided that the Plan does not have to pay for endodontic therapy (D3330), a core build-up (D2950), and 
therapeutic parental drugs (D9610), provided by an out-of-network provider on June 1, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for these 
services. You say that you feel as though they should be covered. 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 allowance amount of $700 was exhausted on date of service June 1, 2022. Therefore, we 
decided that the Plan does not have to pay for endodontic therapy (D3330), a core build-up (D2950), and 
therapeutic parental drugs (D9610), provided by an out-of-network provider on June 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 3 placement of intra-socket biological dressing (D7922) 
provided on July 15, 2022. 
 
You asked the Plan to pay for the placement of intra-socket biological dressing. You say that you received a 
bill for services you received because the provider was out-of-network. You say that you assumed since you 
were visiting the dental clinic in the provider network, all dental treatments rendered would be covered. You 
also say that you were not informed this provider was out-of-network. The Plan denied your request. The Plan 
says placement of intra-socket biological dressing is not listed as a covered service. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the placement of intra-socket 
biological dressing is not among those covered under this benefit. Therefore, we decided that the Plan does not 
have to pay for the 3 placement of intra-socket biological dressing (D7922) provided on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. The Plan denied your request. The Plan says the services requested are not covered 
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 the 
dental services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiographic image (D0330) and the complete dentures 
(D5110 and D5120) provided on May 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental service was approved when checked 
by the office but was later denied. The Plan denied your request. The Plan says the dental services were 
received from an out-of-network (OON) provider and are not covered by your supplemental benefits. Also, the 
Plan confirmed that on May 3, 2022, the provider was told that they were an OON provider, and that the 
enrollee had no OON benefits for the covered services. 
 
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 record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for the radiographic image (D0330) and the complete dentures (D5110 and D5120) provided on May 9, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant tooth #'s 1-8, 9-16, 17-24, 25-32 (D4341). 
 
You asked the Plan to pre-approve the dental services. You say that this procedure was necessary to correct 
long term damage that may have occurred over a number of years. 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 June 29, 2022. Therefore, 
we decided that the Plan does not have to pre-approve periodontal scaling and root planing - four or more teeth 
per quadrant tooth #'s 1-8, 9-16, 17-24, 25-32 (D4341).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for resin-based composite  four or more surfaces, posterior 
(D2394) tooth #30 provided on July 14, 2022. 
 
You asked the Plan to pay for dental services. You say that this service should be covered since it is just a 
filling. The Plan denied your request. The Plan says the coinsurance is correct. 
 
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. Fillings covered once every 24 
months per surface, per tooth. White fillings on posterior teeth will be processed as a silver filling and the 
patient is responsible le for up to the contracted fee. You pay 50% coinsurance after $100 deductible for Class 
2 basic services. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, you pay 50% coinsurance after $100 
deductible. You were charged $100 deductible plus 50% of the allowed amount ($97/allowed amount x 50% = 
$48.50) as well as the difference in the allowed amounts which is $85. The total member responsibility is $100 
deductible + $48.50 + $85 = $233.50. Therefore, we decided that the Plan does not have to pay for resin-based 
composite  four or more surfaces, posterior (D2394) tooth #30 provided on July 14, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve prostate-specific membrane antigen (PSMA) positron emission 
tomography (PET) services. 
 
You asked the Plan to pre-approve PSMA PET scan services. You say that the enrollee has a high-risk prostate 
cancer with fast-growing prostate-specific antigen (PSA) levels, which is highly concerning for metastatic 
disease out of the pelvis. You say that the PSMA scan will be very informative for providers to decide if he 
would be eligible for definitive radiation. You say that it is useful to provide information about future treatment 
options if the disease recurs or metastasize. You say that the requested PSMA scan should be completed before 
the initiation of hormonal therapy. The Plan denied your request. The Plan says that the request is not 
medically necessary because the records show that the request is for initial anti-tumor treatment strategy. 
 
The Plan must follow Medicare rules. Medicare rules say that PET 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 PSMA PET scan services. Our reviewer 
says that the criteria for coverage have been met. Our physician reviewer found PMSA PET scans can be 
considered for staging of soft tissue and bone imaging for high-risk prostate cancer. The enrollee is stated as 
being in the high-risk category. The service is reasonable and medically necessary.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PSMA PET scan services have been met. Therefore, we decided that the Plan 
has to pre-approve prostate-specific membrane antigen (PSMA) positron emission tomography (PET) services.  
 
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional joint fusion (22614) and additional lumbar fusion (63053).

You asked the Plan to pre-approve additional joint fusion and additional lumbar fusion services. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says the request is not medically necessary.

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 additional joint fusion and additional lumbar fusion services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no severe stenosis or instability on imaging. There is no documentation of recent physical therapy for 3 months.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional joint fusion and additional lumbar fusion services have not been met. Therefore, we decided that the Plan does not have to pre-approve additional joint fusion (22614) and additional lumbar fusion (63053).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a computerized tomography (CT) scan on March 24, 2022.

You asked the Plan to waive the copayment for a computerized tomography (CT) scan. You say that you would like to appeal the cost share. 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 $100 copayment for a computerized tomography (CT) scan. 

You have been asked to pay a $100 copayment for a computerized tomography (CT) scan. This item/service 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 computerized tomography (CT) scan on March 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on April 28, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says an additional two units of procedure code 87641 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 87641 is infectious agent detection by nucleic acid (DNA 
or RNA); Staphylococcus aureus, methicillin resistant, amplified probe technique. 
 
We find that CPT code 87641 is not supported in the medical record. Specifically, the records support only 
three units of this code. 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 pay for the laboratory services 
rendered on April 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat-cushion liner/cover (K0108) for a power-
wheelchair seat cushion. 
 
You asked the Plan to pre-approve a seat-cushion liner/cover. You say that the requested item is a medical 
necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met. 
 
The Plan must follow Medicare rules. The rules say that a wheelchair skin protection and positioning seat 
cushion has the characteristics listed in the Medicare rules section of this letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a seat-cushion liner/cover have not been met. Specifically, the request is for a seat-cushion cover. 
The Plan has approved a seat cushion (E2607) that includes a cover. The request is not reasonable and 
necessary. Therefore, we decided that the Plan does not have to pre-approve a seat-cushion liner/cover (K0108) 
for a power-wheelchair seat cushion.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an intervertebral biomechanical device with 
Alloograft. 
 
You asked the Plan to pre-approve insertion of an intervertebral biomechanical device with Allograft. You say 
that this surgery is medically necessary because you have spinal stenosis and are in immense pain. The Plan 
denied your request. The Plan says the requested procedure is not considered reasonable and necessary for your 
condition. 
 
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 insertion of an intervertebral 
biomechanical device with Allograft. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found the requested biomechanical 
device with allograft is not needed to treat spinal stenosis. There is no spine instability and fusion is not needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an intervertebral biomechanical device with Allograft have not been met. Therefore, we decided that the Plan does not have to pre-approve insertion of an intervertebral 
biomechanical device with Alloograft.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care and outpatient 
hospital services provided on March 21, 2022, to June 1, 2022. 
 
You asked the Plan to waive the copayment for the inpatient hospital care and outpatient hospital services. You 
say that you don't think you or the Plan should be responsible for any payments because it is the providers fault 
that you got an infection in your incision. 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 $325 
copayment per day for in-network hospital care, days 1-5, and a $325 copayment for in-network outpatient 
hospital services.  
 
 
 You have been asked to pay a $325 copayment per day for the hospital care ($325 x 3 = $975). You have also 
been asked to pay a $325 copayment for the outpatient hospital services. You have been asked to pay a total of 
$1,300 ($325 + $975 = $1,300). The inpatient hospital care falls within the inpatient hospital care benefit 
category. The outpatient hospital services 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 inpatient hospital care and outpatient hospital services 
provided on March 21, 2022, to June 1, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care after 
November 19, 2022. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot go home. The Plan denied your request. 
The Plan says the denial of authorization for continued SNF care is correct. 
 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 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. 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 continued skilled nursing facility (SNF) care after November 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266), surgical placement of implant body: endosteal implant (D6010), custom fabricated abutment includes 
placement (D6057), abutment supported porcelain/ceramic crown (D6058), bone graft at time of implant 
placement (D6104), and bone replacement graft for ridge preservation - per site (D7953). 
 
You asked the Plan to pre-approve dental services. You say that the requested services are needed. The Plan 
denied your request. The Plan says these services are not covered under your 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. Guided tissue regeneration - 
resorbable barrier, per site (D4266), surgical placement of implant body: endosteal implant (D6010), custom 
fabricated abutment includes placement (D6057), abutment supported porcelain/ceramic crown (D6058), bone 
graft at time of implant placement (D6104), and bone replacement graft for ridge preservation - per site 
(D7953) are not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested dental services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
guided tissue regeneration - resorbable barrier, per site (D4266), surgical placement of implant body: endosteal 
implant (D6010), custom fabricated abutment includes placement (D6057), abutment supported 
porcelain/ceramic crown (D6058), bone graft at time of implant placement (D6104), and bone replacement 
graft for ridge preservation - per site (D7953).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve comprehensive oral evaluation by an oral surgeon. 
 
You asked the Plan to pre-approve dental services. You say that You say that you need the tooth extracted 
because it is painful and infected, it can also affect your heart. The Plan denied your request. The Plan says the 
service is covered but limitations/restrictions apply. 
 
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. Periodic oral or 
comprehensive exam (2 per year). Services must be performed by a participating general dentist. 
 
We looked at the file, the Plans rules, and Medicares rules. The periodic oral or comprehensive exam (2 per 
year) is covered but only when performed by a participating general dentist. Therefore, we decided that the 
Plan does not have to pre-approve comprehensive oral evaluation by an oral surgeon.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a genicular nerve block. 
 
You asked the Plan to pre-approve a genicular nerve block. You say that right genicular radiofrequency block 
for the treatment of osteoarthritis of the knee is medically necessary. The Plan denied your request. The Plan 
says the requested genicular nerve block is not medically necessary. 
 
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 a genicular nerve block. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the role of genicular nerve blocks and radiofrequency ablation is the subject of 
ongoing clinical trials.  It is considered experimental/ investigational at this time. Therefore, the request is 
deemed not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a genicular nerve block have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a genicular nerve block.