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

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you have a very 
important appointments for treatment of your heart and lungs. The Plan denied your request. The Plan says the 
benefit for routine transportation trips is currently exhausted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way routine transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The records show that you have already received coverage for 60 one-way routine transportation trips in the 2022 calendar year.  Based on this 
information, we decided that you have exhausted the Plan maximum benefit for coverage of routine 
transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve filling to support crown (D2950) tooth 12 & 14, white 
pontic crown (D6245) tooth 13 and tooth colored crown to support pontic (D6740) tooth 12 & 14. 
 
You asked the Plan to pre-approve the dental services. You say that the services are medically necessary. 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 filling to 
support crown (D2950) tooth 12 & 14, white pontic crown (D6245) tooth 13 and tooth colored crown to 
support pontic (D6740) tooth 12 & 14.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on March 22, 2022, to March 23, 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 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 the dental services on March 22, 2022, to March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 2D oral photographic images (D0350) provided on July 
6, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like the Plan to pay for the dental 
service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because 
2D oral photographic images are 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 2D 
oral photographic images (D0350) provided on July 6, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the medical eye exam provided on June 30, 
2022. 
 
You asked the Plan to waive the copayment for the medical eye exam. You say that you had a routine eye exam 
and should not be charged for a diagnostic visit. 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 $40 
copayment for each Medicare-covered eye exam.  
 
You have been asked to pay a $40 copayment for the medical eye exam. This medical eye exam falls within the 
vision services benefit category. The medical record shows diagnoses of asteroid hyalosis, dry eye syndrome, 
and cataracts, which makes the visit medical in nature.  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 the medical eye exam provided on June 30, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment  includes placement 
tooth #'s 3, 13, 29, 31 (D6057), and abutment supported porcelain/ceramic crown tooth #'s 3, 13, 29, 31 
(D6058). 
 
You asked the Plan to pre-approve the custom fabricated abutment  includes placement tooth #'s 3, 13, 29, 31 
(D6057), and abutment supported porcelain/ceramic crown tooth #'s 3, 13, 29, 31 (D6058). You say that you 
had half of this procedure last year, but right now your Plan does not cover these implants. You say that you 
have a crown in your mouth but it is practically useless. 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 pre-approve a 
custom fabricated abutment  includes placement tooth #'s 3, 13, 29, 31 (D6057), and abutment supported 
porcelain/ceramic crown tooth #'s 3, 13, 29, 31 (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve immediate mandibular partial denture (D5222). 
 
You asked the Plan to pre-approve immediate mandibular partial denture (D5222). You say that this request is 
for covered dental extractions, but not for replacement of bone structure that is necessary to retain the maxillary 
denture. The Plan denied your request. The Plan says this 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 pre-approve 
immediate mandibular partial denture (D5222).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve stereotactic body radiotherapy (SBRT). 
 
You asked the Plan to pre-approve SBRT. You say that SBRT is reasonable and necessary to treat the patient's 
pancreatic cancer. The Plan denied your request. The Plan says that stereotactic body radiotherapy is 
considered experimental/investigational for the treatment of pancreatic cancer. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve SBRT. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found that for this patient, with unresectable disease after chemotherapy, and no other plans for 
additional systemic treatment, radiotherapy is the only viable option for treatment. So, the relevant question is 
SBRT vs, palliative 3D radiotherapy vs. 5-6 weeks of intensity-modulated radiation therapy (IMRT). SBRT 
would afford better tumor control over palliative treatment and would be more cost-effective than 
conventionally fractionated radiation and would meet standard medical necessary criteria. Studies have shown 
SBRT to be safe and effective for pancreatic cancer. It does not appear that SBRT is necessarily superior to 
conventionally fractionated radiation for unresectable (as the case for this patient), although is an accepted 
treatment modality for pancreatic cancer in general.   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SBRT have been met. Therefore, we decided that the Plan has to pre-approve 
stereotactic body radiotherapy (SBRT).  
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service July 14, 
2022. 
 You asked the Plan to pay for procedure code 70450. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 14, 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 your records must show the tooth has less than a 1:1 
crown to root ratio. 
 
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 
services when the services are medically necessary and reasonable.  
 
Based on this information, we decided that the Plan's rules for coverage of the dental services have not been 
met. Therefore, we decided that the Plan does not have to pay for the dental services on June 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided on July 7, 2022. 
 
You asked the Plan to pay for dental services. You say that the requested procedure should be considered 
preventative and be covered under your benefits. The Plan denied your request. The Plan says this service is 
not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. This benefit includes only 
those items and services specifically listed in your Plan contract. Endodontic therapy, premolar tooth 
(excluding final restoration) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested endodontic therapy, 
premolar tooth (excluding final restoration) (D3320) is not among those covered under this benefit. Therefore, 
we decided that the Plan does not have to pay for endodontic therapy, premolar tooth (excluding final 
restoration) (D3320) provided on July 7, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for injection services provided on May 12, 
2022. 
 
You asked the Plan to waive the coinsurance for injection services. You say that you dont think the 
coinsurance should be this high. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a 20% 
coinsurance for Medicare Part B prescription drugs.  
 
You have been asked to pay a 20% coinsurance for injection services. The total allowed amount for injection 
services $474.94. You are being asked $94.99 ($474.94 x 20% = $94.99). This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the coinsurance for injection services provided on May 12, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from May 25, 2022, to May 30,2022.

You asked the Plan to waive the copayment for inpatient hospital care. You say that you are requesting a formal review for the charges. 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 $295 copayment per day for days 1-4 and a $0 copayment for additional days for inpatient hospital care. 

You have been asked to pay a $295 copayment per day for days 1-4 and a $0 copayment for additional days for inpatient hospital care. The total amount you are being asked to pay is $1,180 ($295 x 4 days = $1,180). 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 care provided from May 25, 2022, to May 30,2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on June 22, 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 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 October 11, 2021. 
Therefore, we decided that the Plan does not have to pay for the dental services on June 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the durable medical equipment purchased from April 28, 
2022, through May 4, 2022, from providers not certified with Medicare. 
 
You asked the Plan to pay for the durable medical equipment. You say that you would like to be reimbursed for 
this equipment. The Plan denied your request. The Plan says payment cannot be made for these services. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the providers at issue are not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the durable medical equipment 
purchased from April 28, 2022, through May 4, 2022, from providers not certified with Medicare.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve osseous surgery (including flap and closure)  one to 
three teeth (D4261). 
 
You asked the Plan to pre-approve dental services. You say that you need the requested services. The Plan 
denied your request. The Plan says this service is not covered under your Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. Osseous surgery (including 
flap and closure)  one to three teeth (D4261) is not covered under the Plans dental benefits. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested osseous surgery 
(including flap and closure)  one to three teeth (D4261) is not among those covered under this benefit. 
Therefore, we decided that the Plan does not have to pre-approve osseous surgery (including flap and closure) 
 one to three teeth (D4261).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical procedure for isolation of tooth with rubber 
dam (D3910) for tooth #12. 
 
You asked the Plan to pre-approve the dental service. You say that you cannot afford the dental procedure and 
would like the Plan to cover it. The Plan denied your request. The Plan says the denial of authorization for this 
service is correct, because the surgical procedure for isolation of tooth with rubber dam 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 pre-approve the 
surgical procedure for isolation of tooth with rubber dam (D3910) for tooth #12.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core build up on tooth #15 (D2950) and a crown on tooth 
#15 (D2740) provided on August 22, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were told that there were no changes to 
your 2022 policy. The Plan denied your request. The Plan says core build up (D2950) and a crown (D2740) are 
not covered by 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 build 
up on tooth #15 (D2950) and a crown on tooth #15 (D2740) provided on August 22, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets LTACH admission criteria. The Plan denied your request. The Plan says the request is not medically necessary.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. All medically necessary care is being provided in the current acute care setting.

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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomographic scan (CT scan) 
provided on July 1, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you should not have to pay the 
copayment. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $275 
copayment for in-network outpatient diagnostic/diagnostic radiology.  
 
You have been asked to pay a $275 copayment for CT scan. The total amount you are being asked to pay is 
$172.81 which is less than the required amount. 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 a CT scan 
provided on July 1, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on May 2, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says Medicare does not 
separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on May 2, 
2022.