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

 
We decided that the Plan does not have to pay for the osseous surgery (including elevation of a full thickness 
flap and closure)  one to three contiguous teeth or tooth bounded spaces per quadrant (D4261), bone 
replacement graft  retained natural tooth  first site in quadrant (D4263), bone replacement graft  retained 
natural tooth  each additional site in quadrant (D4264), biologic materials to aid in soft and osseous tissue 
regeneration (D4265) and guided tissue regeneration - resorbable barrier, per site (D4266) provided April 19, 
2022. 
 
You asked the Plan to pay for the osseous surgery, bone replacement grafts, biologic materials and guided 
tissue regeneration. You say that this type of procedure should always be covered by any insurance company. 
The Plan denied your request. The Plan says these services are not covered under your 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 the 
osseous surgery (including elevation of a full thickness flap and closure)  one to three contiguous teeth or 
tooth bounded spaces per quadrant (D4261), bone replacement graft  retained natural tooth  first site in 
quadrant (D4263), bone replacement graft  retained natural tooth  each additional site in quadrant (D4264), 
biologic materials to aid in soft and osseous tissue regeneration (D4265) and guided tissue regeneration - 
resorbable barrier, per site (D4266) provided April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), core buildup, 
including any pins (D2950), and endodontic therapy, premolar tooth (D3320) provided on April 14, 2022. 
 
You asked the Plan to pay for the dental services. You say that you are on a retired fixed income. The Plan 
denied your request. The Plan says your calendar year maximum benefit has been met. 
 
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 April 14, 2022, with the 
processing of this claim. Therefore, we decided that the Plan does not have to pay for the crown-
porcelain/ceramic (D2740), core buildup, including any pins (D2950), and endodontic therapy, premolar tooth 
(D3320) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740) and core buildup, 
including any pins (D2950) provided on April 12, 2022. 
 
You asked the Plan to pay for the dental services. You say that there was no communication notifying the 
provider's office that they were out-of-network. The Plan denied your request. The Plan says services are only 
covered for in network dentists and our records do not show that your dentist is in our provider network. 
 
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 crown - porcelain/ceramic (D2740) and core buildup, including any pins (D2950) provided on 
April 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) for teeth #2, #3, #8, and #29, provided 
by a participating provider. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to pay for this. The 
Plan denied your request. The Plan says the dental maximum allowance amount 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 January 19, 2022. 
Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) for teeth #2, #3, #8, and 
#29, provided by a participating provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on February 25, 
2021. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you have had this test done in the 
past and you never had to pay this before. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay $110 
copayment for Medicare covered radiological diagnostic services, not including x-rays, performed in a 
physicians office or at a free-standing facility (such as a radiology center or medical clinic).  
 
 
 
 You have been asked to pay $100.73 which is less than the standard $110 copayment for an ultrasound. 
Ultrasounds fall 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 an ultrasound provided on February 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), intraoral - 
complete series of radiographic images (D0210), prophylaxis (D1110), and oral hygiene instructions (D1330) 
on March 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim and that the x-ray should have been 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 for the requested item or service was exhausted on date of service November 2021. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150), 
intraoral - complete series of radiographic images (D0210), prophylaxis (D1110), and oral hygiene instructions 
(D1330) on March 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an extraction, erupted tooth (D7210) provided on January 3, 
2022. 
 
You asked the Plan to pay for the extraction. You say that according to your dental benefits, the plan provides 
50% for a simple extraction. The Plan denied your request. The Plan says this is not a covered service under 
your dental benefit 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 pay for an 
extraction, erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on January 3, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950), endodontic therapy (D3330), retainer 
crown - porcelain fused to noble metal (D6752), and retainer crown - porcelain fused to high noble metal 
(D6750) provided from March 1, 2022, to March 22, 2022. 
 
You asked the Plan to pay for the core buildup, endodontic therapy, and crowns. You say that these services 
were vital to prevent damage to the heart and blood circulatory system. The Plan denied your request. The Plan 
says these services are not on the list of covered dental 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. 
 
  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, including any pins  (D2950), endodontic therapy, molar tooth (D3330), retainer crown - porcelain 
fused to noble metal (D6752), and retainer crown - porcelain fused to high noble metal (D6750) provided from 
March 1, 2022, to March 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a ventilator. The Plan denied your request. The Plan says a setting that could 
be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our physician reviewer 
found that you were admitted to the acute hospital with pain and has hypoventilation syndrome from morbid 
obesity. As a threshold matter, this is not an indication for which coverage is available under the rule. The 
record is insufficient to determine whether you have thoracic restrictive disease. Notwithstanding that fact, the 
provided primary source documentation does not contain sufficient detailed information in the medical record 
to justify the treatment selected. You could be treated with a BiPAP machine with AVAPS capability. The plan 
has indicated that coverage for such a device is available for consideration upon request. Therefore, the 
requested ventilator is not 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 a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment of varicose veins. 
 
You asked the Plan to pre-approve treatment of varicose veins. You say that treatment of varicose veins is 
medically necessary. The Plan denied your request. The Plan says treatment of varicose veins is not medically 
necessary. 
 
The Plan follows Medicare rules.  
 
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 treatment of varicose veins. Our 
reviewer says that treatment of varicose veins is not medically necessary. Our physician reviewer found that the 
documentation does not meet the coverage criteria and does not support the medical necessity of the procedures 
in question. Coverage requires that the patients symptoms be in the territory of the veins to be treated. In this 
case you have evidence of thigh varicosities and pain with moving your knees. These symptoms do not match 
the small saphenous vein territory that is slated for treatment. Additionally, coverage requires documentation of 
conservative treatment including the regular use of compression stockings. This has not been satisfactorily 
documented. Additionally, saphenous vein ablation cannot be considered reasonable or medically necessary 
without an assessment of lower extremity arterial perfusion.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of treatment of varicose veins have not been met. Therefore, we decided that the 
Plan does not have to pre-approve treatment of varicose veins.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for periodontal scaling and root planing 
(D4341 x 2) provided on December 15, 2021. 
 
You asked the Plan to waive the coinsurance for periodontal scaling. You say that you have extra coverage for 
your services to be paid. 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 50% 
coinsurance for periodontal scaling.  You have been asked to pay $121, which is 50% coinsurance for periodontal scaling in each quadrant ($242 allowed amount x 50% coinsurance = $121). You have been asked to pay a total of $242 ($121 coinsurance x 2 quadrants = $242). Periodontal scaling falls within the Dental 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 coinsurance for periodontal scaling and root planing (D4341 x 2) provided on 
December 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the records provided support the need for 
LTACH care. The Plan denied your request. The Plan says the enrollee does not meet the guidelines for 
coverage of LTACH care. The Plan says that the enrollee's needs can safely be met in the current hospital 
setting. Continued care in the short-term acute care hospital is appropriate until the enrollee is stable to transfer 
to a lower level of care such as an inpatient rehabilitation facility, a sub-acute rehabilitation facility or a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the short-term acute care hospital can provide for all of the enrollees present 
inpatient care needs and the enrollee is receiving an appropriate level of care in the present 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia for the enrollee. 
 
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for the enrollee. The Plan 
denied your request. The Plan says that the enrollee does not meet criteria for coverage. 
 
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 Prolia. Our reviewer says that Prolia is 
not medically reasonable and necessary. There is no indication that the patient has had an osteoporotic fracture 
or has tried and failed zoledronic acid. There is no indication that the plan's required drugs would likely be less 
effective and/or likely have adverse effects for the patient. Our physician reviewer found that the enrollee's 
condition does not meet step therapy criteria for Prolia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Prolia have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Prolia for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre 2 continuous glucose monitor (CGM) 
for the enrollee. 
 
You asked the Plan to pre-approve a CGM. You say that this is medically necessary. The Plan denied your 
request. The Plan says that the enrollee is not on insulin. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a 
CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre 2 
continuous glucose monitor (CGM) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that if you do not get this care, it could cause further 
health concerns because you have a heart monitor. The Plan denied your request. The Plan says the stay is not 
medically necessary based on IRF criteria. 
 
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 there is not a reasonable expectation that you will be able to fully participate in and 
benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral 
complete x-ray series (D0210) provided on April 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says your benefit for the requested items or services 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 items or services was exhausted on date of service January 31, 2020. 
Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an 
intraoral complete x-ray series (D0210) provided on April 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for surgical services (procedure code 20610, 27062, 27305, 
38220) provided to the enrollee on November 30, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says 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 the denied codes is: 
 
CPT 20610: 
 
Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); 
without ultrasound guidance 
 
CPT 27062: 
 Excision; trochanteric bursa or calcification 
 
CPT 27305: 
 
Fasciotomy, iliotibial (tenotomy), open 
 
CPT 38220: 
 
Diagnostic bone marrow; aspiration(s) 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records do not 
support the use of the denied procedure codes. 
 
We looked at this coder's review, the file, and Medicare rules. 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 surgical services (procedure code 20610, 27062, 27305, 38220) provided to the enrollee on 
November 30, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the at-home coronavirus test kit (U0002) 
purchased on January 27, 2022. 
 
You asked the Plan to reimburse you for the at-home coronavirus test kit. You say that this is a legitimate 
charge. The Plan denied your request. The Plan says the claim denied correctly. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
coronavirus test kit is an OTC item. Additionally, the record shows that the test kits were purchased prior to the 
coverage date of April 4, 2022. Therefore, we decided that the Plan does not have to reimburse you for the at-
home coronavirus test kit (U0002) purchased on January 27, 2022.