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

 
We decided that the Plan does not have to pay for laboratory services provided on February 1, 2022 by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to appeal the denial of the 
claim. The Plan denied your request. The Plan says the provider is out-of-network and authorization is required 
prior to an out-of-network visit. 
 
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 laboratory services 
provided on February 1, 2022 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hymovis (J7322). 
 
You asked the Plan to pre-approve Hymovis. The Plan denied your request. The Plan says the requested service 
does not meet the health plan's authorization requirements for step therapy.  
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 Hymovis. Our reviewer says that 
Hymovis is not medically reasonable and necessary for the enrollee. Our physician reviewer found the case file 
does not contain documentation that the enrollee tried and failed 2 of the preferred agents. Our reviewer also 
found that the documentation does not support that two of the preferred Hyaluronan agents, Durolane, 
Euflexxa, Supartz, and/or Gelsyn-3, would likely be less effective, and/or would likely have adverse effects for 
the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Hymovis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Hymovis (J7322).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for oral hygiene instructions (D1330) provided by a participating 
provider on January 31, 2022. 
 
You asked the Plan to pay for oral hygiene instructions. 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 oral 
hygiene instructions (D1330) provided by a participating provider on January 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a resin-based composite (D2394) provided by a participating 
provider on January 4, 2022. 
 
You asked the Plan to pay for a resin-based composite. You say that you were told that these services would be 
covered. The Plan denied your request. The Plan says the rendering 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 resin-
based composite (D2394) provided by a participating provider \on January 4, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional payment for the crown - porcelain fused to high 
noble metal (D2750) provided February 8, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to provide additional payment for the crown. You say that you don't understand why this 
service does not receive additional compensation. The Plan denied your request. The Plan says the cost-sharing 
has been applied correctly. 
 
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. The Plan covers the crown 
with 50% coinsurance. For services obtained Out-of-Network the Plan only pays up to a certain amount. If you 
choose to see an Out-of-Network dentist you might be billed by that provider for any amount greater than what 
the Plan pays. 
 
We looked at the file, and Medicare rules. The Plan provided documentation showing that they have covered 
50% of the allowed amount for this service. You are being asked to pay 50% of the allowed amount plus the 
difference between the allowed amount and the total cost billed by the OON provider. This means you are 
being asked to pay the correct amount based on your contract with the Plan. Therefore, we decided that the 
Plan does not have to provide additional payment for the crown - porcelain fused to high noble metal (D2750) 
provided February 8, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) 
(72148) provided on January 28, 2022. 
 
You asked the Plan to waive the copayment for the MRI. You say that the services should be covered as you 
disagree with the charges. The Plan denied your request. The Plan says the cost-sharing applied correctly based 
on the services provided. 
 
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 $200 
copayment for Outpatient diagnostic tests and therapeutic services and supplies.  
 
 You have been asked to pay a $198.50 copayment for an MRI. MRIs fall within the Outpatient diagnostic tests 
and therapeutic services and supplies 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 
magnetic resonance imaging (MRI) (72148) provided on January 28, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided 
by an out of network dentist. 
 
You asked the Plan to pre-approve the dental service. You say that you would like to continue to see your long 
time dentist who is not with your plan. You say that it is too risky for you to be treated by dentists other that 
those familiar with you and your health conditions. The Plan denied your request. The Plan says dental services 
performed out of network are 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested comprehensive oral 
evaluation is not among those covered under this benefit when performed out of network. Therefore, we 
decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) to be provided by 
an out of network dentist.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient rehabilitation facility (IRF) services provided 
from November 11, 2021, to November 23, 2021. 
 
You asked the Plan to pay for the IRF care. You say that you would like this claim to be reprocessed and 
reimbursed per your contract. The Plan denied your request. The Plan says this request is not medically 
necessary.  
The Plan must follow Medicare rules. The rules say that inpatient rehabilitation facility (IRF) admission is 
covered only when it is medically reasonable and necessary as described in the Medicare rules section. 
 
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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not need intensive therapies, consisting of at least 3 hours of therapy 
per day at least 5 days per week with multidisciplinary approach to daily therapy in an IRF. Our reviewer also 
found that the IRF admission was not medically necessary based on medical stability, lack of medical 
complexity, lack of acute rehab nursing needs. 
 
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 IRF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the inpatient rehabilitation facility (IRF) services provided from November 11, 2021, to 
November 23, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150), complete series 
of intraoral x-rays (D0210), prophylaxis (D1110), and semi-precision attachment abutment (D6052) provided 
on December 14, 2021 by an out-of-network (OON) provider. 
 
  You asked the Plan to pay for the comprehensive oral evaluation, complete series of intraoral x-rays, 
prophylaxis, and semi-precision attachment abutment. You say that you were not advised that the location 
and/or provider were OON. The Plan denied your request. The Plan says you self-referred to an OON provider. 
The Plan also says that there are no records of calls to customer service requesting network providers within 
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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are received OON. Therefore, we decided that the Plan does not have to pay for the 
comprehensive oral evaluation (D0150), complete series of intraoral x-rays (D0210), prophylaxis (D1110), and 
semi-precision attachment abutment (D6052) provided on December 14, 2021 by an out-of-network (OON) 
provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an overdenture  complete mandibular (D5865) and 
precision attachments, by report (D5862). 
 
You asked the Plan to pre-approve a complete lower overdenture and precision attachments. You say that these 
services are medically necessary for your physical and emotional health. The Plan denied your request. The 
Plan says these services are not covered under your 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 an 
overdenture  complete mandibular (D5865) and precision attachments, by report (D5862).  
 
Your complaint about potentially not being provided with a list of covered benefits when signing up for the 
Plan and concern about the types of services covered or not covered under your benefits is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare 
does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve partial dentures for the upper and lower jaws (D5225, 
D5226). 
 
You asked the Plan to pre-approve partial dentures. You say that you are unhappy with your current dentures, 
and they have had to be adjusted multiple times. You would like replacements. The Plan denied your request. 
The Plan says you previously received partial dentures for both the upper and lower arches in December of 
2021. Your benefit covers a maximum of one denture per arch every five years. 
 
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. The Plan covers one 
removable denture per arch every five years. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the documentation supports that the 
dentures are requested in a frequency that is not covered under this benefit.  
 
Therefore, we decided that the Plan does not have to pre-approve partial dentures for the upper and lower jaws 
(D5225, D5226).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the crown for tooth #18 (CPT code D6751). 
 
You asked the Plan to pre-approve the dental services. You say that the service is necessary. The Plan denied 
your request. The Plan says you exhausted your benefit frequency limit. 
 
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. 
 
Your claim history shows that you previously received a crown on tooth 18 on December 20, 2019, which 
means you will be eligible for the Plan to make payment on another crown for tooth 18 on December 20, 2024. 
The 2022 health plan contract says one (1) crown per sixty (60) months per tooth. Therefore, we decided that 
the Plan does not have to pre-approve the crown for tooth #18 (CPT code D6751).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement of nails provided on January 3, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the debridement of nails. You say that this provider is a participating provider 
with the Plan and no prior authorization is necessary for this service in the office. The Plan denied your request. 
The Plan says the rendering provider is a non-participating provider, and there is no referring provider involved 
in these services. The Plan also says that they did not authorize any services for this provider. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to 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 the debridement of nails provided on January 3, 
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 porcelain crown (D2740) provided on January 17, 2022. 
 
You asked the Plan to pay for the dental service. You say that half of your tooth broke off. You say that your 
dentist advised the best fix was for a crown. You say that you never received an Evidence of Coverage. You 
say that you contacted the plan for your current coverage. You also say that you were advised your plan would 
cover between a third and half of the cost. The Plan denied your request. The Plan says porcelain crown is not 
listed as a covered service. 
 
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 
porcelain crown (D2740) provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 9, 2022 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 laboratory services provided on March 9, 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 complete maxillary and mandibular dentures (D5120 and 
D5110) provided by a participating provider on January 5, 2022. 
 
You asked the Plan to pay for complete maxillary and mandibular dentures. You say that you have had the 
same dentures for 25 years. You say that you would like to replace these old dentures. The Plan denied your 
request. The Plan says the rendered dental services are not covered 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 complete maxillary and mandibular dentures 
(D5120 and D5110) provided by a participating provider on January 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the periapical x-rays (D0220, D0230 x 2) provided on 
November 30, 2021. 
 
You asked the Plan to pay for the dental services. You say that you were told by the dental office that the 
periapical x-rays were going to be covered. The Plan denied your request. The Plan says periapical x-rays are 
not listed as covered services. 
 
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 periapical x-rays are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the periapical x-
rays (D0220, D0230 x 2) provided on November 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99211) provided March 3, 2022. 
 
You asked the Plan to pay for the chiropractic office visit. You say that you could have gone to the other 
provider but you were in too much pain and could not drive 55 miles. This provider is 3 miles from you and 
you needed help fast. The Plan denied your request. The Plan says this service is not covered when rendered by 
a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the outpatient office visit (99211) provided March 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on April 28, 2021 by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for an office visit. You say that you would like to request reconsideration for 
payment. The Plan denied your request. The Plan says the provider is out-of-network and authorization is 
required prior to an out-of-network visit. 
 
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 an office visit provided on April 28, 2021 by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a consult with a Periodontist. 
 
You asked the Plan to pre-approve the consult. You say that you need to see a periodontist for deep cleanings. 
The Plan denied your request. The Plan says your contract says only provides coverage for dental services 
when they are performed by a participating general dentist. The Plan also says that dental services performed 
by a periodontist are 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. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
covered when they are provided by anyone other than a participating general dentist. Therefore, we decided 
that the Plan does not have to pre-approve a consult with a Periodontist.