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

 
We decided that the Plan does not have to pre-approve dental services (D0330, D7210). 
 
You asked the Plan to pre-approve dental services. You say that you were unable to obtain emergency dental 
work timely from a network provider. The Plan denied your request. The Plan says rules for coverage for 
dental services have not been met. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers dental 
services when the services are obtained from a participating dental provider.  
 
We looked at the file and Medicare rules. In this case, the provider at issue is not a participating dental provider 
with the Plan. Based on this information, we decided that the Plan's rules for coverage of dental services have 
not been met. Therefore, we decided that the Plan does not have to pre-approve dental services (D0330, D7210).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the eyewear purchased on June 11, 2021 from an out-of-
network (OON) provider. 
 You asked the Plan to pay for the eyewear. The Plan denied your request. The Plan says you purchased 
eyewear from an OON provider. The Plan also says that there is no indication that you were referred to an 
OON provider to purchase eyewear. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when services are obtained from a provider in the Plans vision vendor 
network. 
 
We looked at the file and the Plan's rules. Specifically, the eyewear was purchased from an OON provider, and 
your Plan does not have OON coverage. Based on this information, we decided that the Plan's rules for 
coverage of the eyewear have not been met. Therefore, we decided that the Plan does not have to pay for the 
eyewear purchased on June 11, 2021 from an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of Gel-One. 
 
You asked the Plan to pre-approve Gel-One. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires 
a trial of Durolane, Monovisc, or Synvisc-One before it will approve Gel-One. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Gel-One. Our reviewer says that the 
enrollee does not meet the Medicare criteria for a step therapy exception for Gel-One. Our physician reviewer 
found the enrollee has not tried and failed the Plan's preferred drugs of Durolane, Monovisc, or Synvisc-One. 
The record does not show that these drugs would likely be less effective and/or have adverse effects for the 
enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Gel-One have not been met. Therefore, we decided that the Plan does not have 
to pre-approve use of Gel-One.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the second opinion to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve the second opinion. You say that there is a conflict between your primary 
care provider and the specialist about your diagnosis. You say that is why you need a second opinion. The Plan 
denied your request. The Plan says the provider is out-of-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 second opinion. We found no exception that would require the Plan to pre-
approve the second opinion. Therefore, we decided that the Plan does not have to pre-approve the second 
opinion to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete upper denture (D5110) and partial lower 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the previous dentist did not make the 
dentures correctly. You say that you are having issues now. You also say that you have not been able to eat 
correctly. The Plan denied your request. The Plan says dentures are covered once every 5 years. The Plan also 
says that the frequency limit has been reached. 
 
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 dentures are covered once every 5 
years, the frequency limit has been reached. The record shows that the Plan paid for a complete upper denture 
and a partial lower denture that you received on August 6, 2021. Therefore, we decided that the Plan does not 
have to pre-approve a complete upper denture (D5110) and partial lower denture (D5214).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Prolonged service in the inpatient or observation setting (99356) 
provided on January 27, 2022. 
 
You asked the Plan to pay for code 99356. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says that the records do not support the services billed. 
 
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 99356 is Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the 
usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and 
Management service). 
 
We find that CPT code 99356 is supported in the medical record. Specifically, 99356 is an add-on code. 
Parenthetical Guidelines specific to 99356 supports the use of code 99223 with code 99356. Based on this 
information, we decided that Medicare rules for coverage of code 99356 have been met. Therefore, we decided 
that the Plan has to pay for the Prolonged service in the inpatient or observation setting (99356) provided on 
January 27, 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 the rubber dam (D3910 x 2), and canal preparation and 
fitting of preformed dowel or post (D3950 x 2). 
 
You asked the Plan to pay for the dental services. You say that you need these services to put on the prosthesis. 
You also say that you cannot pay for these services. The Plan denied your request. The Plan says rubber dam is 
not listed as a covered service. The Plan says that canal preparation and fitting of preformed dowel or post is 
not listed as a covered service either. 
 
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 rubber dams, and canal 
preparation and fitting of preformed dowel or posts are not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for the rubber dam (D3910 x 2), and canal preparation and fitting 
of preformed dowel or post (D3950 x 2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
You asked the Plan to pre-approve Zilretta. You say that this injection service is medically reasonable and 
necessary. The Plan denied your request. The Plan says the efficacy and safety of repeated administration of 
Zilretta not been demonstrated. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 Zilretta. Our reviewer says that repeat 
Zilretta injection services are not medically reasonable and necessary. Our physician reviewer found that you 
have a diagnosis of unilateral primary osteoarthritis of the right knee. You have received multiple intra-
articular corticosteroid injections in the affected knee over many years, including in February, March, and May, 
2021. On March 21, 2022, it is documented that the enrollee "still has some element of relief from the 
corticosteroid injection." While the Food and Drug Administration approved label no longer precludes the 
repeat dosing of Zilretta, the clinical documentation does not support that the repeated dosing requested in this 
case is an accepted standard of medical practice, and is at least as beneficial as existing and medically 
appropriate alternatives.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Zilretta have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Zilretta.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to adjust your copayment for emergency room services on June 1, 2021. 
 
You asked the Plan to adjust your copayment for emergency room services on June 1, 2021. You say that you 
cannot afford the copayment. The Plan denied your request. The Plan says you are responsible to pay $85 for 
each emergency room visit. 
 
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 an $85 
copayment for Emergency Care.  
 
You have been asked to pay an $85 copayment for emergency room services. Emergency room services fall 
within the Emergency Care benefit category. Your appeal tells us that that you cannot afford the copayment. 
Your copayment is required regardless of the reason. 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 adjust your copayment for 
emergency room services on June 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density study (77080 x1) provided on January 28, 2022.
You asked the Plan to pay for DXA bone density study. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says only 1 unit of code 77080 is eligible for payment based on MUE rules.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 77080 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of DXA bone density study have not been met. Therefore, we decided that the Plan does not have to pay for the dual-energy X-ray absorptiometry (DXA) bone density study (77080 x1) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants. 
 
You asked the Plan to pre-approve dental implants. You say that your bottom plate will not work anymore, and 
you need the implants to eat. The Plan denied your request. The Plan says dental implants are not a covered 
benefit on 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. 
 
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 
dental implants.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental services provided by an out-of-network provider. 
 
You asked the Plan to pre-approve dental services. You say that you have been seeing this doctor for over 10 
years. The Plan denied your request. The Plan says there are in-network providers available to provide these 
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 Plan covers covered 
dental services when the services are provided in-network. 
 
We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of dental services have not been met. Therefore, we decided that the Plan does not have to pre-
approve dental services provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigation-per quadrant (D4941). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollee's 
contractual policy. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival 
irrigation-per quadrant (D4941).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for services provided on January 18, 2022, 
and January 21, 2022. 
 
You asked the Plan to waive the $10 copayment for an Urgent Care Facility visit on January 18, 2022, and the 
$325 copayment for ground ambulance transportation provided on January 21, 2022.  You say that you should 
not have a copayment for these services. The Plan denied your request. The Plan says enrollees pay a $10 
copayment for each Urgent Care Facility visit and a $325 copayment for each one-way trip via ground 
ambulance.  
 
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 Urgently Care Facility. Your contract with the Plan also says that you must pay a $325 
copayment per one-way trip via ground ambulance. 
 
You also asked the Plan to waive the $325 copayment for ground ambulance transportation provided on 
January 21, 2022. You say that you should not have a copayment for this service. The Plan denied your request. 
The Plan says enrollees pay a $325 copayment for each one-way trip via ground ambulance. 
 
You have been asked to pay a $10 copayment for the Urgent Care Facility visit provided on January 18, 2021. 
Urgent Care Facility visits fall within the Urgently needed services benefit category. You have also been asked 
to pay a $325 copayment for ground ambulance transportation provided on January 21, 2022. Ground 
ambulance transportation visit falls within the Ambulance Services benefit category. This means that you have 
been asked to pay the correct amounts 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 services provided on January 18, 2022, and January 21, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation device 
(HFCWOD). 
 
You asked the Plan to pre-approve a HFCWOD. You say that this device is medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage of the HFCWOD 
have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say the HFCWODs are covered only when they are 
medically necessary for patients with cystic fibrosis, bronchiectasis, or certain neuromuscular diseases.  
 
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 HFCWOD. Our reviewer says that the 
requested HFCWOD is not medically reasonable and necessary. Our physician reviewer found treatment with 
HFCWOD is considered not medically necessary. This patient has aspiration pneumonia and Kennedy disease (x-linked spinal bulbar muscular atrophy). There is no diagnosis of bronchiectasis, cystic fibrosis, or one of the 
covered neuromuscular diseases. There is no documentation that other airway clearance measures, such as 
chest physiotherapy or the flutter valve, have been tried and failed. The denial is upheld. 
 
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 HFCWOD have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a high frequency chest wall oscillation device (HFCWOD).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery (D3431). 
 
You asked the Plan to pre-approve the dental service. You say that you really need this treatment. The Plan 
denied your request. The Plan says biologic materials to aid in soft and osseous tissue regeneration in 
conjunction with periradicular surgery is not 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 requested biologic materials to aid 
in soft and osseous tissue regeneration in conjunction with periradicular surgery is not among those covered 
under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic materials to aid in 
soft and osseous tissue regeneration in conjunction with periradicular surgery (D3431).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve gingival irrigationper quadrant (D4921). 
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says this service is not a covered benefit under the enrollees 
contractual policy. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve gingival 
irrigationper quadrant (D4921).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implant maintenance procedures (D6080). 
 
You asked the Plan to pre-approve implant maintenance procedures. You say that these dental services are 
medical necessary. The Plan denied your request. The Plan says implant maintenance procedures (D6080) are 
not covered by your routine 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 
implant maintenance procedures (D6080).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve removal of impacted tooth, completely bony (D7241), 
cone beam computed tomography (CT) (D0365), and incisional biopsy of oral tissue, hard (D7285). 
 
You asked the Plan to pre-approve the dental services. You say that your dentist advised your tooth could break 
your jaw. You say that this causes you constant worry and anxiety. You also say that you need these services. 
The Plan denied your request. The Plan says removal of impacted tooth, cone beam CT, and incisional biopsy 
of oral tissue are not listed as covered 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 removal of impacted 
tooth, cone beam CT, and incisional biopsy of oral tissue are not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve removal of impacted tooth, completely bony 
(D7241), cone beam computed tomography (CT) (D0365), and incisional biopsy of oral tissue, hard (D7285).