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

 
We decided that the Plan does not have to pay for periodontal scaling and root planing (D4341/D4342), 
provided on November 7, 2022. 
 
You asked the Plan to pay for periodontal scaling and root planing. You say that you cannot pay for this. 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 50% 
coinsurance for dental services/class 2 basic services.  
 
You have been asked to pay a 50% coinsurance of the allowed amount for periodontal scaling and root planing. 
The total allowed amount is $336.48. The correct total amount you are being asked to pay is $168.24 (D336.48 
x 50% coinsurance = $168.24).  This item/service falls within the dental services/class 2 basic 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 pay for periodontal scaling and root planing (D4341/D4342), provided 
on November 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the MRI of the cervical spinal canal. 
 
You asked the Plan to pre-approve the cervical spinal MRI. You say that the x-ray report was not dictated, and 
the appeal deadline was missed. The Plan denied your request. The Plan says the service is not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 the cervical spinal MRI. Our reviewer 
says that the MRI is not medically necessary. Our physician reviewer found that the enrollee has bilateral 
shoulder pain and bilateral bursitis. The enrollees x-ray showed diffuse degenerative changes. However, there 
was no red flag concerning the cervical spinal and there is no contraindication to a six-week trial of physical 
therapy before receiving an MRI. 
 
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 cervical spinal MRI have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the MRI of the cervical spinal canal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power wheelchair to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve a power wheelchair. You say that you are requesting reconsideration. The 
Plan denied your request. The Plan says the enrollee must receive their care from a network provider (for more 
information about this, see Section 2 in Chapter 3). In most cases, care the enrollee receives from an out-of-
network provider (a provider who is not part of the plans network) will not be covered. This means that the 
enrollee will have to pay the provider in full for the services furnished. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
 
 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a power wheelchair to be provided by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulance services provided on 
October 29, 2022. 
 
You asked the Plan to waive the copayment for the ambulance services. You say that you did not have the 
option to be transported without an ambulance. 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 for ground ambulance services. 
 
You have been asked to pay a $295 copayment for the ambulance services. This item/service falls within the 
ground ambulance 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 waive the copayment for the 
ambulance services provided on October 29, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hot or cold packs therapy (97010), electrical stimulation 
(97032), manual therapy (97140), massage therapy (97124), and the extraspinal chiropractic manipulative 
treatment (98943) provided from August 15, 2022, through October 31, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit. 
 
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 services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the hot or cold packs therapy (97010), electrical stimulation (97032), 
manual therapy (97140), massage therapy (97124), and the extraspinal chiropractic manipulative treatment 
(98943) provided from August 15, 2022, through October 31, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150). 
 
You asked the Plan to pre-approve the dental services. You say that this dentist is the best. 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 a 
comprehensive oral evaluation (D0150).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the office services to be provided by an out-of-network 
provider. 
 
You asked the Plan to pre-approve the out-of-network services. You say that you need this provider so you can 
have the treatment done without waiting two weeks for an appointment. The Plan denied your request. The 
Plan says the requested provider is out-of-network and retired. The Plan states you can establish with a new 
contracted provider within two weeks. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
the office services to be provided by an out-of-network provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve treatment with Dupixent subcutaneous injection. 
 
You asked the Plan to pre-approve Dupixent. You say that the requested drug is a medical necessity for the 
enrollee. The Plan denied your request. The Plan says rules for coverage of self-administered drugs have not 
been met. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drug requested here is not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Dupixent 
subcutaneous injection.  
 Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodontal scaling and root planing (D4341) provided on 
November 7, 2022. 
 
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 a 
periodontal scaling and root planing (D4341) provided on November 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for three impacted tooth removals (D7230) provided on May 16, 
2022. 
 
You asked the Plan to pay for an impacted tooth removal. You say that you would like the Plan to 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, 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 three 
impacted tooth removals (D7230) provided on May 16, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for durable medical equipment (DME) 
provided on October 24, 2022. 
 
You asked the Plan to waive the coinsurance for durable medical equipment (DME). You say that you disagree 
with the coinsurance. 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 20% 
coinsurance for durable medical equipment (DME). 
 
You have been asked to pay 20% coinsurance for durable medical equipment (DME). This item/service falls 
within the durable medical equipment (DME) 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 coinsurance 
for durable medical equipment (DME) provided on October 24, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a skilled nursing facility visit provided on August 12, 2022. 
 
You asked the Plan to pay for a skilled nursing facility visit. You say that the records attached support the 
services provided. 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 a skilled nursing facility 
visit provided on August 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation hospital services (G0378) provided from 
June 4, 2022, to June 8, 2022. 
 
You asked the Plan to pay for the observation hospital services (G0378). You say that you would like the Plan 
to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 
as 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 G0378 is Hospital observation service, per hour.  
We find that CPT code G0378 is not supported in the medical record. Specifically, it is not appropriate to bill 
more than one line of observational services per claim. In this case multiple lines of CPT code G0378 have 
been billed. This does not meet Medicare guidelines for billing or reimbursement consideration. Based on this 
information, we decided that Medicare rules for coverage of the observation hospital services (G0378) have not 
been met. Therefore, we decided that the Plan does not have to pay for the observation hospital services 
(G0378) provided from June 4, 2022, to June 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medication assisted treatment provided on August 29, 2022. 
 
You asked the Plan to pay for medication assisted treatment. You say that the necessary information was not 
provided at the time of claim submission. 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 medication assisted 
treatment provided on August 29, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a periodic oral exam and cleaning (D0120, D1110) 
provided on October 10, 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 denial. The Plan denied your request. The Plan says your  $1,000 dental annual benefit 
maximum allowance for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service June 29, 2022. Therefore, 
we decided that the Plan does not have to pay more for a periodic oral exam and cleaning (D0120, D1110) 
provided on October 10, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on October 19, 2022. 
 
You asked the Plan to pay for the dental services. You say that you believe this should covered and paid. The 
Plan denied your request. The Plan says your combined allowance for supplemental preventive and 
comprehensive dental services was 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 Plan 
processes claims as they are received - the claim for November 30, 2022 was processed prior to the claim for 
October 19, 2022.The record shows your combined dental allowance was exhausted on date of service 
November 30, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided on 
October 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an opioid treatment program provided on October 24, 2022. 
 
You asked the Plan to pay for an opioid treatment program. You say that the records attached support the 
services provided. 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 an opioid treatment 
program provided on October 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided on November 08, 2022. 
 
You asked the Plan to pay for anesthesia services. You say that this was medically necessary and should be 
covered. 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 anesthesia services 
provided on November 08, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the denosumab injections provided on 
Mary 24, 2022, and November 22, 2022. 
 
You asked the Plan to waive the coinsurance for the injections. You say that you did not agree to the cost for 
these injections. 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 10% 
coinsurance for Medicare Part B drugs and drug administration.  
 
You have been asked to pay up to 10% coinsurance for each injection. These items/services fall within the 
Medicare Part B drugs 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 coinsurance for the 
denosumab injections provided on Mary 24, 2022, and November 22, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 3 additional dental x-rays and oral hygiene instructions 
(D0230, D1330, D0350) provided on November 16, 2022. 
 
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 your benefit for the intraoral x-ray was exhausted 
on the appealed claim. Coverage for the oral hygiene instructions denied correctly as it does 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service November 16, 2022. 
Therefore, we decided that the Plan does not have to pay for 3 additional dental x-rays and oral hygiene 
instructions (D0230, D1330, D0350) provided on November 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft (D7953) provided on July 11, 2022, 
to July 20, 2022. 
 
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 a bone 
replacement graft (D7953) provided on July 11, 2022, to July 20, 2022.