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

 
We decided that the Plan does not have to pre-approve a crown (D2740) on tooth 30. 
 
You asked the Plan to pre-approve a crown (D2740) on tooth 30. You say that you would like to appeal. The 
Plan denied your request. The Plan says this service is not covered. 
 
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. Crowns (D2740) are excluded 
from this benefit. 
 
 
  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 a 
crown (D2740) on tooth 30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve periodontal scaling and root planing (D4342) 
 
You asked the Plan to pre-approve the periodontal scaling and root planing. 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 pre-approve 
periodontal scaling and root planing (D4342)
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from May 1, 2022, through 
May 2, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says that the acute inpatient hospital care provided 
was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 these services. Our reviewer says that the 
documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer 
found that the enrollee presented to the emergency department (ED) on April 26, 2022 with complaints of 
abdominal discomfort right sided flank pain, radiating to the right of the abdomen two to three days prior to 
this visit. He also had complaints of cough, nausea, and vomiting. He was evaluated with a history, physical 
exam, and laboratory studies. He was diagnosed with abdominal pain and acute decompensated liver cirrhosis. 
He was admitted and received medical treatment. He responded to medical therapy and continued to improve 
with treatment. The review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollees necessary hospital care (including earlier ED and/or 
observation care) would span two midnights.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have been met. Therefore, we decided that the Plan has to pay for 
the acute inpatient hospital care provided from May 1, 2022, through May 2, 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 osseous surgery (including elevation of a full thickness flap 
and closure)  four or more contiguous teeth or tooth bounded spaces per quadrant (D4260), bone replacement 
graft  retained natural tooth  first site in quadrant (D4263), and guided tissue regeneration - resorbable 
barrier, per site (D4266) provided on February 5, 2022 and March 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the surgeries have already been completed on 
half of your mouth, the other half you chose not to continue because you need a fast appeal. You say it was 
your understanding that the insurance would cover 50 percent of the cost. The Plan denied your request. The 
Plan says these services are 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 pay for osseous 
surgery (including elevation of a full thickness flap and closure)  four or more contiguous teeth or tooth 
bounded spaces per quadrant (D4260), bone replacement graft  retained natural tooth  first site in quadrant 
(D4263), and guided tissue regeneration - resorbable barrier, per site (D4266) provided on February 5, 2022 
and March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of service January 
25, 2022. 
 You asked the Plan to pay for procedure code 81345-GZ. You say that this test was medically necessary and 
should be paid. The Plan denied your request. The Plan says payment for code 81345-GZ is bundled into 
payment for code 0089U. 
 
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, we have confirmed that code 
81345-GZ is a column II code to column I code 0089U. This claim has not been billed with an appropriate 
modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code 81345-GZ billed for date of 
service January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the complete mandibular denture (D5120) provided on May 
4, 2022. 
 
You asked the Plan to pay for the complete mandibular denture. You say that you do not have money to pay for 
the bottom denture right now. The Plan denied your request. The Plan says your annual dental benefit 
maximum 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, the Plan offers a $3,000 annual dental 
benefit maximum. The contract says that after your annual maximum benefit maximum has been met, you are 
responsible for the full charges of any additional dental services. The record shows that you met the annual 
maximum benefit on May 4, 2022, and your annual maximum benefit has been exhausted. Therefore, we 
decided that the Plan does not have to pay for the complete mandibular denture (D5120) provided on May 4, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on July 15, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration of the 
denied claim. The Plan denied your request. The Plan says the 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 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 dental 
services on July 15, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) provided on March 16, 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 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 September 22, 2021. 
Therefore, we decided that the Plan does not have to pay for prophylaxis (D1110) provided on March 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services on May 12, 2022.

You asked the Plan to waive the copayment for inpatient hospital services. You say that you would like to appeal the cost share. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 35% coinsurance for inpatient hospital services. 

You have been asked to pay a 35% coinsurance for inpatient hospital services. 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 copayment for inpatient hospital services on May 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the cost share for the porcelain/ceramic crown
(D2740) provided on May 31, 2022.
You asked the Plan to waive the cost share. You say that you are requesting a reconsideration of the
Plan's denial for payment. The Plan denied your request. The Plan says this cost share was applied
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). This Dental benefit includes a
$1,500 combined allowance for supplemental preventive and comprehensive dental services every
year. The member is responsible for any amount over and above the allowance amount.

You have been asked to pay $401(Plan's allowable amount of $1,598 - $1,197 payment) for the
dental item provided. The dental benefit includes a $1,500 combined allowance for supplemental
preventive and comprehensive dental services every year.

The Plan issued payment previously for the dental services provided on April 26, 2022 in the
amount of $303 and $1,197 for the dental crown provided on May 31, 2022. The maximum
payment allowable has been issued for the dental services provided this calendar year; therefore,
your remaining liability is $401. This cost sharing is a contractual obligation you agreed to pay
when you enrolled in the Plan. The Plan contract states that the member is responsible for any
amount over and above the allowance amount. Therefore, we decided that the Plan does not have to
waive the cost share for the porcelain/ceramic crown (D2740) provided on May 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on May 24, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges. The Plan denied your request. The Plan says your $1,0000 dental benefit maximum allowance 
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 May 24, 2022. Therefore, 
we decided that the Plan does not have to pay for the dental services provided on May 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve plastic side guard (K0108) seat pouch (K0108) custom 
assembly/mounting foam footplate (K0108) and push tracker (K0108). 
 
You asked the Plan to pre-approve wheelchair component or accessory, not otherwise specified. You say that 
you are appealing to get a replacement wheelchair in order to continue completing activities of daily living in 
your home as you cannot use a cane or walker to do these activities. The Plan denied your request. The Plan 
says the plastic side guard, seat pouch, custom assembly/mounting foam footplate and push tracker are 
convenience or comfort items and do not primarily serve a medical purpose. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.   
We looked at the file, and Medicare rules. The plastic side guard are to shield the enrollee from pebbles, 
splashes and debris while outdoors. The seat pouch is for holding personal items. the foam footplate is to add 
personal comfort. The push tracker tracks distance, pushes and coast time and does not serve a medical 
purpose. Based on this information, we decided that Medicare rules for coverage of wheelchair component or 
accessory, not otherwise specified have not been met. Therefore, we decided that the Plan does not have to pre-
approve plastic side guard (K0108) seat pouch (K0108) custom assembly/mounting foam footplate (K0108) 
and push tracker (K0108).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay the full cost for upper dentures (D5130, D5110) provided on 
March 10, 2021, and June 10, 2022, and lower dentures (D5120) provided on June 10, 2022. 
 
You asked the Plan to pay the full cost for two sets of upper dentures and one set of lower dentures. You say 
that you believe these claims were submitted in error. The Plan denied your request. The Plan says these claims 
processed correctly. 
 
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 Plan 
covers dentures once every 60 months with a 50% coinsurance. You have been asked to pay a 50% coinsurance 
for the upper dentures provided on March 10, 2021, and the lower dentures provided on June 10, 2022. The 
upper dentures provided on June 10, 2022, were denied because they were provided less than 60 months after 
the upper dentures provided on March 10, 2021. Therefore, we decided that the Plan does not have to pay the full cost for upper dentures (D5130, D5110) provided on March 10, 2021, and June 10, 2022, and lower 
dentures (D5120) provided on June 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core build-up including pins (D2950) and the crown (D2740) provided on May 26, 2022.

You asked the Plan to pay for the dental services. You say that you are appealing the denied claim. The Plan denied your request. The Plan says your annual maximum benefit 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 Plan's 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 May 26, 2022. Therefore, we decided that the Plan does not have to pay for the core build-up including pins (D2950) and the crown (D2740) provided on May 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a dental re-evaluation (D0170) provided on May 24, 2022. 
 
You asked the Plan to pay for the dental re-evaluation. 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 dental 
re-evaluation (D0170) provided on May 24, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periodontal maintenance (D4910) provided on July 28, 
2022. 
 
You asked the Plan to pay for the dental service. You say that the dental service should be included under the 
routine cleaning benefit. The Plan denied your request. The Plan says the denial of payment for this service is 
correct, because the periodontal maintenance is 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 
periodontal maintenance (D4910) provided on July 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown (D2740) provided on January 7, 2022. 
 
You asked the Plan to pay for the crown (D2740). You say that the service was billed as out-of-network and no 
reimbursement or payment was received. The Plan denied your request. The Plan says the 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 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 crown 
(D2740) provided on January 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve upper partials. 
 
You asked the Plan to pre-approve the dental services. You say that your upper partials were lost in a fire. 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. The Plan rules say they only 
cover the replacements of removable and fixed prosthesis once every 60 months. 
 
 
  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 February 23, 2022. 
Therefore, we decided that the Plan does not have to pre-approve upper partials.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown - porcelain/ceramic tooth #14 (D2740). 
 
You asked the Plan to pre-approve the crown - porcelain/ceramic tooth #14 (D2740). You say that the Plan has 
to have coverage for crowns and you were told it would be covered. 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 a 
crown - porcelain/ceramic tooth #14 (D2740).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve OsteoAmp allograft. 
 
You asked the Plan to pre-approve OsteoAmp allograft. You say that the enrollee has failed conservative 
treatments. The Plan denied your request. The Plan says the clinical value and effectiveness of OsteoAmp in 
the setting of anterior cervical spine fusion surgery have not been demonstrated in peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve OsteoAmp allograft. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found OsteoAmp allograft is experimental in spinal surgery. More research is needed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of OsteoAmp allograft have not been met. Therefore, we decided that the Plan 
does not have to pre-approve OsteoAmp allograft.