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

 
We decided that the Plan does not have to pre-approve adding a metal substructure to an acrylic full denture 
(D5876). 
 
You asked the Plan to pre-approve adding substructure to a denture. You say that dentures will improve your 
quality of life. The Plan denied your request. The Plan says adding a metal substructure to an acrylic full 
denture (D5876) is not covered by your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
adding a metal substructure to an acrylic full denture (D5876).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON MRI. You say that the enrollee is claustrophobic and the out-of-
network facility offers wide-bore MRI. The Plan denied your request. The Plan says the requested MRI is 
available in-network.  The Plan has identified two network providers within 30 miles of the enrollee's home 
where the requested wide-bore MRI service can be provided. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
magnetic resonance imaging (MRI) 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 removal of impacted tooth - soft tissue tooth #'s 1 and 
16 (D7220). 
 
You asked the Plan to pre-approve the removal of impacted tooth - soft tissue tooth #'s 1 and 16 (D7220). You 
say that you have discomfort, especially the decay/infection in your upper right wisdom tooth and this is 
considered a necessary service. The Plan denied your request. The Plan says this service is not covered under 
the benefit package. 
 
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 
removal of impacted tooth - soft tissue tooth #'s 1 and 16 (D7220).
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 member would strongly benefit from 
and improve with the admission to a long-term acute care hospital. The Plan denied your request. The Plan says 
the member can be treated at a lower level of care. 
 
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 enrollee appears to be a candidate for short-term acute hospital (STACH) care for 
wound care management and infection treatment but is unlikely to require additional care services. Short-term 
acute care services can safely be provided at the current facility until enrollee is more stable to be transferred to 
a lower level of care. The enrollee does not require services at the LTACH that are not already available at an 
STACH. Transfer to the LTACH is not medically necessary and would not be clinically advantageous over a 
STACH. 
 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a computerized tomography (CT) scan of the chest to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the CT scan. You say that you need to get the CT scan done. The Plan 
denied your request. The Plan says the requested provider is an OON provider. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a computerized tomography (CT) scan of the chest 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 crowns (D2740) for tooth #4 and #18. 
 
You asked the Plan to pre-approve the dental services. You say that the crowns are necessary to save your 
teeth. The Plan denied your request. The Plan says the denial of authorization for these services is correct, 
because crowns are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  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 
crowns (D2740) for tooth #4 and #18.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two additional trips for routine transportation. 
 
You asked the Plan to pre-approve two additional trips. You say that you are requesting additional 
transportation to see your providers to get new prosthetics, as your previous ones were damaged. The Plan 
denied your request. The Plan says your benefit only allows 48 trips for this service. The Plan also says you 
have exceeded your benefit limit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of up to 48 one-way trips per year.  
 We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve two additional trips for routine transportation.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve physical therapy. You say that transportation to another facility during the 
winter is unnecessary. The Plan denied your request. The Plan says there is in-network provider within 10 
miles of the home zip code. 
 
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 items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
physical therapy services 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 pay for dental services (D2393, D2392, D2391) provided on August 
18, 2022 to August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental 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. 
 
 
  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 dental services (D2393, D2392, D2391) provided on August 18, 2022 to August 22, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 3, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed. 
 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 76641 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 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service October 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation and prophylaxis (D1110, D0120) 
provided on March 15, 2022 to September 22, 2022. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis. You say that the services should be 
covered as you disagree with the denial. The Plan denied your request. The Plan says the services denied 
correctly as they do not fall within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation and prophylaxis (D1110, D0120) provided on March 15, 2022 to September 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingivectomy (D4212) and the medicaments (D9630) for 
tooth #29 provided on August 27, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were medically necessary, 
and you would like the denial overturned. The Plan denied your request. The Plan says the denial of payment 
for these services is correct, because the gingivectomy and the medicaments are not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  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 
gingivectomy (D4212) and the medicaments (D9630) for tooth #29 provided on August 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services (D0150, D0220, D0230, D0274, 
D0330, D4342) provided on August 18, 2022 by an out-of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says you are responsible for any charged 
amount above the Plans cost-sharing amount when your services are received from an out-of-network 
provider. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services (D0150, D0220, D0230, 
D0274, D0330, D4342) provided on August 18, 2022 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lenses, progressive lenses, photochromatic lenses, and anti-
reflective coating provided on August 23, 2022. 
 You asked the Plan to pay for lenses, progressive lenses, photochromatic lenses, and anti-reflective coating. 
You say that your glasses and frames are the most comfortable and serviceable due to the flexibility and 
strength of the frames. The Plan denied your request. The Plan says the cost of your eyeglasses exceeds the 
plan's maximum allowed benefit of $200 every two years. The Plan also says that you are responsible for the 
difference after the limit has been exhausted. 
 
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 up to $200 once every two years for routine eyewear. 
 
We looked at the file and the Plan's rules. The Plan rules say that you $0 up to the Plan benefit limit of $200 
(once every two years) for routine eyewear. The record shows that this benefit was exhausted. Based on this 
information, we decided that the Plan's rules for coverage of lenses, progressive lenses, photochromatic lenses, 
and anti-reflective coating have not been met. Therefore, we decided that the Plan does not have to pay for 
lenses, progressive lenses, photochromatic lenses, and anti-reflective coating provided on August 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Observation care discharge day management (99217) 
provided on September 17, 2022. 
 
You asked the Plan to pay for procedure code 99217. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as 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. The rules also say that when a patient is 
admitted for observation care and then is discharged on a different calendar date, the physician shall report 
Initial Observation Care, from CPT code range 99218 - 99220, and CPT observation care discharge CPT code 
99217. 
 
We looked at the file and Medicare rules. In this case, the file shows that an initial observation care procedure 
code was billed for date of service September 16, 2022, however; was denied for payment due to a billing 
issue. The Plan says the claim at issue in this appeal can be reprocessed once the claim for the initial 
observation care procedure code has been billed correctly. Therefore, we decided that the Plan does not have to 
pay for the Observation care discharge day management (99217) provided on September 17, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical nutrition therapy provided on August 02, 2022. 
 
You asked the Plan to pay for medical nutrition therapy. You say that you do not understand why the claim was 
denied because you are in-network with the Plan. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for medical nutrition 
therapy provided on August 02, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a cone beam CT scan (D0364) provided on May 11, 2022. 
 
You asked the Plan to pay for the cone beam CT scan. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as they do 
not fall within your plan benefits. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for a cone beam CT scan (D0364) 
provided on May 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110). 
 
You asked the Plan to pre-approve the dental services. You say that the enrollee has an existing upper denture 
that is fractured and unrepairable. You also say that the enrollee is currently wearing no denture at this time. 
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 25, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided on July 20, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for a digital, binaural hearing aid (V5261). You say that you should be covered 
because you were initially examined by a Plan specialist and confirmed you needed it. The Plan denied your 
request. The Plan says the provider is out-of-network, and authorization to utilize an out-of-network provider 
was not obtained. 
 
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 had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for a digital, binaural hearing aid (V5261) provided 
on July 20, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the repair of an implant supported prosthesis, by report 
(D6090 x 2) provided on August 30, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the repair of an 
implant supported prosthesis, by report (D6090 x 2) provided on August 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-rays provided on September 14, 2022. 
 
You asked the Plan to pay for the x-rays. You say that the records provided support medical necessity. The 
Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the x-rays provided on 
September 14, 2022.