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

 
We decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access 
(D3331) x2 
 
You asked the Plan to pre-approve dental services. You say that your provider said you need the requested 
services, so you are hoping the request will be approved. The Plan denied your request. The Plan says this 
service is 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. Treatment of root canal 
obstruction; non-surgical access (D3331) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested treatment of root canal 
obstruction; non-surgical access (D3331) x2 is not among those covered under this benefit. Therefore, we 
decided that the Plan does not have to pre-approve treatment of root canal obstruction; non-surgical access 
(D3331) x2.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an overdenture - complete maxillary (D5863) provided on 
September 14, 2021. 
 
You asked the Plan to pay for the dental services. You say that you would like authorization for these services. 
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 July 15, 2019. Therefore, 
we decided that the Plan does not have to pay for an overdenture - complete maxillary (D5863) provided on 
September 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary partial denture (D5213) provided by an out-of-
network provider on January 20, 2022. 
 
You asked the Plan to pay for the dental services. You say that the dentist advised you that this would be 
payable under your plan. 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 a maxillary partial denture (D5213) provided by an out-of-network provider on January 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete radiographic series (D0210), panoramic 
radiographic (D0330), and a 2D/oral photographic imaging (D0350), provided by a participating provider on 
April 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for this. 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 D0210 was exhausted on date of service February 4, 2020, and D0330 was exhausted on 
May 27, 2021. D0350 is not a covered benefit. Therefore, we decided that the Plan does not have to pay for a 
complete radiographic series (D0210), panoramic radiographic (D0330), and a 2D/oral photographic imaging 
(D0350), provided by a participating provider on April 11, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an inpatient hospital stay provided from 
July 7, 2022, to July 14, 2022. 
 
You asked the Plan to waive the coinsurance for an inpatient hospital stay. You say that you disagree with your 
cost share for the inpatient hospital stay. 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 10% 
coinsurance per stay for each Medicare-covered inpatient hospital admission or stay.  
 
 
  You have been asked to pay $1,299.62, which is less than the standard 10% coinsurance for an inpatient 
hospital stay because you met your in-network maximum out-of-pocket. This item/service falls within the 
Inpatient Hospital Care 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 an 
inpatient hospital stay provided from July 7, 2022, to July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 6-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the enrollee needs additional 
trips due to a fall. The Plan denied your request. The Plan says the enrollee has exhausted the transportation 
benefit. 
 
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 6 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 additional trips for routine transportation beyond the Plan's 
6-trip limit.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan provided on August 16, 2022. 
 
You asked the Plan to pay for the 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 meet the 
clinical requirements to be approved. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the CT scan. Our reviewer says that the 
service is not medically necessary Our physician reviewer found the services should be denied as there was no 
clinical indication to examine the arteries of the lower extremities. 
 
 
  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 CT scan have not been met. Therefore, we decided that the Plan does not 
have to pay for a CT scan provided on August 16, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home visit provided on August 05, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for home visit. You say that you are requesting reconsideration. The Plan denied 
your request. The Plan says the enrollee must receive their care from a network provider (for more information 
about this, see Section 2 in this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 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 home visit provided on August 05, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve crown - Porcelain/Ceramic (D2740). 
 
You asked the Plan to pre-approve dental services. You say that you need the crown. The Plan denied your 
request. The Plan says multiple attempts were made to obtain documentation as to why the treatment being 
requested was medically necessary. The provider has not submitted the required documentation. 
 
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 dental 
services when the services are medically necessary and reasonable.  
 
We looked at the file, and Medicare rules. Based on this information, no medical records were submitted, it 
cannot be determined that the requested services are necessary. 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 crown - 
Porcelain/Ceramic (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for over-the-counter COVID-19 tests provided on January 12, 
2022. 
 
You asked the Plan to pay for over-the-counter COVID-19 tests. You say that you were told that you could 
apply for reimbursement for up to 8 COVID-19 test kits through the end of April 2022. The Plan denied your 
request. The Plan says per the Centers for Medicare & Medicaid Services (CMS), plans or issuers may, but are 
not required by federal law to provide such coverage for over-the-counter at-home COVID-19 tests purchased 
before April 4, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that as of April 4, 2022, that will cover up to eight 
over-the-counter COVID-19 tests each calendar month, at no cost to you.  
 
 
  We looked at the file and Medicare rules. The record shows the COVID-19 tests were purchased on January 
12, 2022, which is before April 4, 2022. Based on this information, we decided that Medicare rules for 
coverage of over-the-counter COVID-19 tests have not been met. Therefore, we decided that the Plan does not 
have to pay for over-the-counter COVID-19 tests provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on July 12, 
2022. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you disagree with the 
copayment. 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 $30 
copayment for physician/practitioner services/specialist visit.  
 
You have been asked to pay a $30 copayment for specialist office visit. This item/service falls within the 
physician/practitioner services/specialist visit 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 specialist office visit provided on July 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 32-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you need additional 
transportation. The Plan denied your request. The Plan says you have exhausted your transportation benefit. 
 
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 32 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 additional trips for routine transportation beyond the Plan's 
32-trip limit.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for outpatient surgery provided on May 25, 
2022. 
 
You asked the Plan to waive the copayment for outpatient surgery. You say that you disagree with the 
copayment. 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 $270 
copayment for outpatient surgery.  
 
You have been asked to pay a $270 copayment for outpatient surgery. However, you are being asked to pay 
$235.04 which is less than the required amount. This item/service falls within the outpatient surgery 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 outpatient surgery provided on May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on February 17, 2022. 
 
You asked the Plan to waive the coinsurance for DME. You say that you disagree with the coinsurance. 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 20% 
coinsurance for Durable medical equipment (DME).  
 
You have been asked to pay a 20% coinsurance for DME. The total allowed amount for the DME is $1,446.90. 
The amount you are being asked to pay is $289.38 ($1,446.90 x 20% = $289.38). 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 durable medical equipment (DME) provided on February 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve these items. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says these items are not a covered benefit for your condition. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not meet criteria for coverage of orthotics as you do not wear a shoe that is an 
integral part of a covered brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan 
provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-
approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endodontic therapy (D3310) provided by an out-of-
network provider. 
 
You asked the Plan to pre-approve the dental services. You say that you need this dental work. The Plan denied 
your request. The Plan says dental services from an out-of-network provider 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. 
 
You are requesting 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 pre-approve endodontic 
therapy (D3310) provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient echocardiology provided on July 27, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient echocardiology. You say that the services were medically necessary, 
and the records attached support the services. The Plan denied your request. The Plan says there is no prior 
authorization on file for the services. 
 
 
 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 outpatient echocardiology provided on July 27, 
2022, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Monovisc (J7327). 
 
You asked the Plan to pre-approve Monovisc. You say that Monovisc is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc, Synvisc, and Synvisc One is required before alternatives can 
be considered. 
 
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 Monovisc. Our reviewer says that 
Monovisc is not medically necessary. Our physician reviewer found the records do not show a trial of the plan 
preferred drugs or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Monovisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Monovisc (J7327).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Hospital discharge day management services (99238) 
provided on July 13, 2022. 
 
You asked the Plan to pay for procedure code 99238. 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 the Medicare approved amount for global 
surgery procedures includes payment for the above services related to the surgery when furnished by the 
physician who performs the surgery. 
 
We looked at the file and Medicare rules. The procedure in question was provided within the 10-day global 
period for the surgical procedure (code 36558) that was provided on July 8, 2022. Code 99238 was not billed 
with a modifier indicating this was unrelated to the original procedure. This means that payment for the 
procedure was included in the payment for the original surgical procedure. Therefore, we decided that the Plan 
does not have to pay for the Hospital discharge day management services (99238) provided on July 13, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for physical therapy service provided from 
August 2, 2022, to August 31, 2022. 
 
You asked the Plan to waive the copayment for physical therapy service. You say that you disagree with the 
copayment. 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 $35 
copayment for outpatient rehabilitation services.  
 
You have been asked to pay a $35 copayment for physical therapy service. The total allowed amount you are 
being asked to pay is $245 ($35 x 7 visits = $245). 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 
physical therapy service provided from August 2, 2022, to August 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (83735) provided on February 25, 2021. 
 
You asked the Plan to pay for the lab services. You say that additional diagnoses from the provider were 
received late. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until July 18, 2022. This means that more than 
one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the 
Plan does not have to pay for the lab services (83735) provided on February 25, 2021.