Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for repair, paraesophageal hiatal hernia (including 
fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis rendered on 
August 28, 2022. 
 
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 code 43333 is "Repair, paraesophageal hiatal hernia (including 
fundoplication), via laparotomy, except neonatal; with implantation of mesh or other prosthesis." 
 
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 in this case, the record indicates 
that the enrollee underwent a surgical procedure.  The record provided does not document that mesh was 
implanted.  
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 repair, paraesophageal hiatal hernia (including fundoplication), via laparotomy, except 
neonatal; with implantation of mesh or other prosthesis rendered on August 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that this drug is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc OR Supartz FX 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 Euflexxa. Our reviewer says that 
Euflexxa 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 Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation services. 
 You asked the Plan to pre-approve the transportation services. You say that the services are medically 
necessary. The Plan denied your request. The Plan says you do not meet the medical necessity criteria required 
for approval of the transportation services requested. You do not have both qualifying diagnoses. 
 
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 routine transportation when have congestive heart failure which is a plan requirement.  
 
We looked at your request, the records in the case file, and the rules. The record shows you are being treated 
for diabetes and not congestive heart failure. Based on this information, we decided that the Plans rules for 
coverage of routine transportation have not been met. Therefore, we decided that the Plan does not have to pre-
approve transportation services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous positive airway pressure (CPAP) device 
provided on November 26, 2022. 
 
You asked the Plan to pay for the continuous positive airway pressure (CPAP) device. You say that the 
equipment is medically necessary. 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 continuous positive 
airway pressure (CPAP) device provided on November 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a power operated vehicle provided on August 24, 2022, by 
an out-of-network (OON) provider. 
 
You asked the Plan to pay for the power operated vehicle. You say that you were unaware of the network 
guidelines and thought you would be reimbursed. The Plan denied your request. The Plan says 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 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 power operated vehicle provided on August 24, 
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 frames, the progressive lenses, and the routine eye exam 
provided on September 30, 2022. 
 
You asked the Plan to pay for the vision services. You say that you had a five month wait at the in-network 
provider. You say you thought you would get reimbursed for the inexpensive frames. The Plan denied your 
request. The Plan says you had a five month wait at the in-network provider. You say you thought you would 
get reimbursed for the inexpensive frames. 
 
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 provided by a network provider. 
 
We looked at the file and the Plan's rules. Specifically, the provider was out-of-network. Based on this 
information, we decided that the Plan's rules for coverage of the vision services have not been met. Therefore, 
we decided that the Plan does not have to pay for the frames, the progressive lenses, and the routine eye exam 
provided on September 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a crown (D2740) and a prefabricated post and core (D2954) 
for tooth #12 provided on November 28, 2022. 
 
You asked the Plan to pay for the dental services. You say that your summary of benefits say that crowns are 
covered, and the dentist office called the Plan prior to the services for authorization. The Plan denied your 
request. The Plan says the denial of payment for these services is correct because the crown and a prefabricated 
post and core are not covered by the Plan. Also, it was verified that the proper benefits and eligibility were told, 
and crowns were never discussed on the call. 
 
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 crown 
(D2740) and a prefabricated post and core (D2954) for tooth #12 provided on November 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a cone beam computed tomography (CT) (D0383) 
provided on December 9, 2022. 
 
You asked the Plan to pay more 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 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. 
 
 vYou 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 a cone beam computed tomography (CT) 
(D0383) provided on December 9, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup services (D2950) provided on January 4, 2023. 
 
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 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 core 
buildup services (D2950) provided on January 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for routine periodic exam completed during check-up 
(D0120), standard adult dental cleaning (D1110), bitewings X-Rays for evaluation of the teeth and bone 
(D0274), and x-rays for closer evaluation around the roots of teeth (D0220, D0230) provided on December 6, 
2022. 
 
You asked the Plan to pay more for the dental services. You say that this should be covered. 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 routine periodic exam completed during 
check-up (D0120), standard adult dental cleaning (D1110), bitewings X-Rays for evaluation of the teeth and 
bone (D0274), and x-rays for closer evaluation around the roots of teeth (D0220, D0230) provided on 
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation, intraoral x-ray, bitewing x-ray, and 
filling (D0140, D2331, D0220, D0274) provided on December 26, 2022, to January 10, 2023. 
 
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 a limited oral evaluation, intraoral x-ray, bitewing x-ray, and filling (D0140, D2331, D0220, D0274) 
provided on December 26, 2022, to January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on December 13, 
2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you needed this evaluation. The Plan 
denied your request. The Plan says the rendered dental 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 a limited 
oral evaluation (D0140) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), intraoral radiographic 
images (D0220 and D0230), bitewings (D0274), and a cleaning (D1110) provided on November 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that dental x-rays are listed as a basic coverage of 
your dental program, and you are appealing the denied service. The Plan denied your request. The Plan says 
your annual maximum dental benefit for the year 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. On January 
24, 2022, the Plan paid $140 for dental services. On May 2, 2022, the Plan paid $65 for dental services. On 
October 3, 2022, the Plan paid $795 for dental services. For the year of 2022 the Plan paid $1,000 ($140 paid + 
$65 paid + $795 paid) for dental services. Therefore, your dental benefit for the year of 2022 was exhausted on 
the date of service of October 3, 2022. Therefore, we decided that the Plan does not have to pay for a periodic 
oral evaluation (D0120), intraoral radiographic images (D0220 and D0230), bitewings (D0274), and a cleaning 
(D1110) provided on November 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), an intraoral 
image (D0220), and extractions (D7140/D7210), provided on November 29, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you feel like these services should be paid. 
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 a comprehensive oral evaluation (D0150), an 
intraoral image (D0220), and extractions (D7140/D7210), provided on November 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the endodontic therapy, of a premolar tooth (excluding 
final restoration) (D3320) provided on December 13, 2022. 
 
You asked the Plan to pay more for the dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. 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 the endodontic therapy, of a premolar tooth 
(excluding final restoration) (D3320) provided on December 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral radiographic images (D0230) and the 
application of fluoride (D1206) provided on December 20, 2022. 
  You asked the Plan to pay for the dental services. You say that you have sent copies of the receipts for 
reimbursement for the dental services you received. The Plan denied your request. The Plan says your benefit 
for the intraoral radiographic images has already been exhausted. Also, the denial of payment for the 
application of fluoride is correct because it 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, certain limitations apply. The record 
shows the Plan paid for the intraoral radiographic image (D0220) on December 20, 2022; therefore, your 
benefit for the intraoral radiographic image (D0230) was exhausted on the date of service of December 20, 
2022. The application of fluoride is not covered under the Plans dental benefit. Therefore, we decided that the 
Plan does not have to pay for the intraoral radiographic images (D0230) and the application of fluoride 
(D1206) provided on December 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), periapical radiographic 
image (D0220), and pay more for the crown (D2740) for tooth #26 provided by an out-of-network provider on 
December 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that you went to the same dentist office and did not 
you would see a different dentist. The Plan denied your request. The Plan says your benefit for the limited oral 
evaluation and periapical radiographic image has already been exhausted. Also, the proper cost share was 
applied to the crown at an in-network benefit level. 
 
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 limited oral evaluation and periapical radiographic image was exhausted on the date 
of service of May 16, 2022. Also, the record shows the Plan reprocessed the payment for the crown at an in-
network benefit level with the total allowed of $1,425 and a coinsurance of $712.50 ($1,425 total x 50% 
coinsurance). 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 for a limited oral evaluation (D0140), periapical 
radiographic image (D0220), and pay more for the crown (D2740) for tooth #26 provided by an out-of-network 
provider on December 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for x-rays of the humerus provided on September 8, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the x-rays. You say that the enrollee did not have a choice of providers for this 
service. The Plan denied your request. The Plan says 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 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 x-rays of the humerus provided on September 8, 
2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on August 12, 2022. 
 
You asked the Plan to pay for the office visit. 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 office visit provided 
on August 12, 2022.