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

 
We decided that the Plan does not have to reimburse the cost share amount for a Cerec crown on tooth #9 
(D2740) provided on April 5, 2022. 
 
You asked the Plan to reimburse the cost share amount for a crown. You say that you are due a refund of $600 
for a crown. The Plan denied your request. The Plan says you have been charged the correct cost sharing 
amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $425 
copayment for a crown (D2740).  The record shows you signed a consent form for the upgraded crown materials. You have been asked to pay a $425 copayment for a crown. You have also been asked to pay $325 for a Cerec crown upgrade.  A crown falls within the Dental Services benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to reimburse the cost share amount for a 
Cerec crown on tooth #9 (D2740) provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an endodontist visit to be rendered by an out-of-network 
(OON) provider 
 
You asked the Plan to pre-approve the endodontist visit. You say that you would like to see this endodontist 
because you have seen this endodontist before, and your current dentist is referring you back to them. 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 an 
endodontist visit to be rendered by an out-of-network (OON) provider
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bicuspid root canal (D3320), prefabricated post and core 
(D2954), and a metal crown (D2750), provided by an out-of-network provider on May 10, 2022. 
 
You asked the Plan to pay for a bicuspid root canal, prefabricated post and core, and a metal crown. You say 
that you would like the Plan to pay for these services. The Plan denied your request. The Plan says this claim 
has been 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.  
 
We looked at the file and Medicare rules. The Plan has paid $780 towards the total charges of $2,050 for the 
services rendered. The enrollees annual maximum allowance amount of $1,500 has already been met. Based 
on this information, we decided that the Plan's rules for coverage of a bicuspid root canal, prefabricated post 
and core, and a metal crown have not been met. Therefore, we decided that the Plan does not have to pay for a 
bicuspid root canal (D3320), prefabricated post and core (D2954), and a metal crown (D2750), provided by an 
out-of-network provider on May 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), additional intraoral periapical x-ray (D0230), cone beam computed 
tomography (CT) image capture (D0380), and endodontic therapy (D3330) provided on March 11, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told these services would be covered. 
The Plan denied your request. The Plan says your dental allowance for the Plan 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. The record 
shows your dental allowance was exhausted on date of service March 15, 2022. Therefore, we decided that the 
Plan does not have to pay for the problem focused limited oral evaluation (D0140), first intraoral periapical x-
ray (D0220), additional intraoral periapical x-ray (D0230), cone beam computed tomography (CT) image 
capture (D0380), and endodontic therapy (D3330) provided on March 11, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a mandibular partial denture (D5214) 
 
You asked the Plan to pre-approve 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 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 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 07/15/2022. Therefore, 
we decided that the Plan does not have to pre-approve a mandibular partial denture (D5214)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the removal of torus mandibularis (D7473) 
 
You asked the Plan to pre-approve the removal of torus mandibularis. 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 Plan's 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 the 
removal of torus mandibularis (D7473).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Avsola.

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the step therapy requirement is not met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has ulcerative colitis previously treated with Inflectra and sulfasalazine. She has not tried and failed the Plan's second required drug, Stelara. The records do not support that the required drug is contraindicated or less effective; therefore, Avsola is not reasonable or medically necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Avsola.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown (D2740) and a core build-up (D2950) provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve a crown and a core build-up. You say that you do not understand why the 
Plan will not pay for this. The Plan denied your request. The Plan says these services have been correctly 
denied. 
 
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, D2950 is not among those covered 
under this benefit. D2740 is a covered benefit and has been processed correctly according to the out-of-network 
benefit rules. Therefore, we decided that the Plan does not have to pre-approve a crown (D2740) and a core 
build-up (D2950) provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown (D2750) 
 
You asked the Plan to pre-approve the dental crown. 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 denied correctly as 
you do not qualify for them. 
 
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 the dental 
crown when the services are medically necessary and reasonable.  
 
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 dental crown. Our physician 
reviewer found that given the presentation of the tooth on the provided x-rays it would not be reasonable to 
place a crown given either the scenario of there being a missing smaller filling, or if the damage extended to the 
bony crest. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental crown have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a dental crown (D2750)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment on tooth #14 (D6057) and 
an abutment supported crown on tooth #14 (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says a custom fabricated abutment (D6057) and an abutment 
supported crown (D6058) are not covered by your routine 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 a 
custom fabricated abutment on tooth #14 (D6057) and an abutment supported crown on tooth #14 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a crown on tooth #14 (D2751). 
 
You asked the Plan to pre-approve a crown. You say that this service is medically necessary. The Plan denied 
your request. The Plan says that there is an unacceptable root canal fill on tooth #14. 
 
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 a crown when 
the services are medically necessary and reasonable.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a crown. Our reviewer says that the 
coverage criteria has not been met. Our physician reviewer found that a review of the documentation indicates 
that there appears to be inadequate root canal fill and condensation. For a crown to be approved the inadequate 
root canal fill must be addressed to insure a more favorable prognosis. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a crown have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a crown on tooth #14 (D2751).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (D4260). 
 
You asked the Plan to pre-approve the dental surgery. You say that the service is medically necessary. The Plan 
denied your request. The Plan says the services are not medically necessary. 
 
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 the dental 
surgery when the services are medically necessary and reasonable.  
 
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 dental surgery. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the documentation provided does not 
support the need for this service. The radiographs provided were insufficient to determine if osseous surgery 
was required. 
 
  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the dental surgery have not been met. Therefore, we decided that the Plan does 
not have to pre-approve osseous surgery (D4260).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on 
March 10, 2022, billed with code 83789. 
 
You asked the Plan to pay for the unspecified mass spectrometry testing. You say that this claim should be paid 
due to medical necessity. The Plan denied your request. The Plan says the drug testing was covered, but no 
payment can be made for code 83789. 
 The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the unspecified mass spectrometry testing have not been met. Specifically, we find that the testing 
described by the billed code is considered specimen validity testing which is not separately payable. Therefore, 
we decided that the Plan does not have to pay for the unspecified mass spectrometry testing provided on March 
10, 2022, billed with code 83789.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve crowns (D2750) for teeth # 8 and 9. 
 
You asked the Plan to pre-approve the dental services. You say that the existing crowns are cracked. You also 
say that the enrollee needs to be able to chew food. The Plan denied your request. The Plan says that there are 
already crowns on these teeth. The Plan also says that the crowns are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not provided digital quality x-rays. We requested these 
documents, but none were received. Without the digital quality x-rays, it cannot be determined that the crowns 
are not medically necessary. Therefore, we decided that the Plan has to pre-approve crowns (D2750) for teeth # 
8 and 9.  
 
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 a limited oral evaluation (D0140) provided by a participating 
provider on April 25, 2022. 
 
You asked the Plan to pay for a limited oral evaluation. You say that you would like the Plan to pay for this. 
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 by a participating provider on April 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150) and a 
complete series of radiographic imaging (D0210) provided by an out-of-network provider on May 24, 2022. 
 
You asked the Plan to pay more for the dental services. You say that you were told that this provider took your 
insurance. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plan's 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 Plan's coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's 
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) 
and a complete series of radiographic imaging (D0210) provided by an out-of-network provider on May 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an acute inpatient hospital admission and shoulder joint 
replacement surgery. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that the inpatient admission is 
medically necessary. The Plan denied your request. The Plan says the requested inpatient admission is 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 pre-approve acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission have been met in 
this case. Our physician reviewer found the surgery in this case is a routine procedure. The reviewer found that 
it may be safely done with a 48-hour observational stay. Therefore, the reviewer found that the requested 
inpatient admission is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an acute inpatient hospital admission and shoulder joint replacement 
surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) provided on 
April 13, 2022. 
 
You asked the Plan to pay for the dental services. You say that you only have 17 teeth, and it would be a waste 
of time, resources, and money to do this procedure in more than one visit. 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 April 13, 2022. 
Therefore, we decided that the Plan does not have to pay for periodontal scaling and root planing (D4341) 
provided on April 13, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on May 3, 2022. 
 
You asked the Plan to pay for the dental services. You say that you needed a second opinion. 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 March 8, 2022. 
Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on 
May 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller with harness, electronic 
connection, and power seat elevation system. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation system is not covered. 
Medicare rules say that an expandable controller is used to control multiple power options. 
 
We looked at the file and Medicare rules. The requested power seat elevation system is not covered by 
Medicare. The file shows that the expandable harness is not needed to control the approved power switches. 
Therefore, we decided that the Plan does not have to pre-approve an expandable controller with harness, 
electronic connection, and power seat elevation system.