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

 
We decided that the Plan does not have to pre-approve a comprehensive oral evaluation (D0150) and an 
extraction (D7210) provided by an oral surgeon. 
 
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 dental services from a provider other than a participating 
dentist 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 oral surgeon. 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 a 
provider other than a participating dentist. Therefore, we decided that the Plan does not have to pre-approve a 
comprehensive oral evaluation (D0150) and an extraction (D7210) provided by an oral surgeon.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan provided on April 5, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you were not aware the copayment 
would be so high, and you cannot afford it. The Plan denied your request. The Plan says the copayment applied 
is correct. 
 
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 $225 
copayment for advanced imaging services.  
 
You have been asked to pay $225 copayment for CT scan. CT scans 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 CT scan provided on April 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for implant supported crowns (D6065) and custom fabricated 
abutments (D6067), provided by a participating provider. 
 
You asked the Plan to pay for implant supported crowns and custom fabricated abutments. You say that these 
services are medically necessary. The Plan denied your request. The Plan says the requested 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 implant 
supported crowns (D6065) and custom fabricated abutments (D6067), provided by a participating provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hearing aid repairs (V5299) provided on August 18, 
2021, and January 14, 2022. 
 
You asked the Plan to pay for the hearing aid repairs. You say that you feel since the benefits guide does not 
specify new hearing aids are covered, that repairs should be included and covered. The Plan denied your 
request. The Plan says only the purchase of new hearing aids is covered. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when they are purchased new.  
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aid repairs have not been met. Therefore, we decided that the Plan does not have to pay 
for the hearing aid repairs (V5299) provided on August 18, 2021, and January 14, 2022.
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 need additional 
transportation trips. The Plan denied your request. The Plan says you have utilized the maximum number of 
transportation trips allowed per year. 
 
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 24 trips per year.  
 We looked at your request, the records in the case file, and the rules. 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 pay for endodontic therapy on tooth #23 (D3310) provided on May 
5, 2022. 
 
You asked the Plan to pay for the dental services. You say that you had to have this service done again because 
it was not done properly the first time. 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 April 6, 2021. Therefore, 
we decided that the Plan does not have to pay for endodontic therapy on tooth #23 (D3310) provided on May 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment - includes placement 
(D6057) provided March 16, 2022. 
 
You asked the Plan to pay for the custom fabricated abutment. You say that you feel the Plan has failed to 
consider your coverage. The Plan denied your request. The Plan says this service is 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 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 pay for the 
custom fabricated abutment - includes placement (D6057) provided March 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Vertiflex device. 
 
You asked the Plan to pre-approve the Vertiflex device. You say that the requested Vertiflex device is 
medically necessary. The Plan denied your request. The Plan says the requested Vertiflex device is not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
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 Vertiflex device. Our reviewer says 
that the requested Vertiflex device is not medically necessary. Our physician reviewer found the Vertiflex 
device is experimental. More research is needed. At this time, the requested Vertiflex device is not 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 the Vertiflex device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the Vertiflex device.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for prophylaxis (D1110) and a periodic oral evaluation (D0120) 
provided on December 30, 2021. 
 
You asked the Plan to pay for prophylaxis and an evaluation. You say that there are no other providers in your 
area who deal with chemically sensitive people. The Plan denied your request. The Plan says the provider has 
opted out of Medicare and is not eligible for payment. 
 
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary 
for items or services provided directly by a physician or practitioner who has opted out of the program except 
in cases involving emergencies or urgently needed care. 
 
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who 
has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for 
prophylaxis (D1110) and a periodic oral evaluation (D0120) provided on December 30, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for recement crowns on tooth #18 and 20 (D2920) provided on 
April 20, 2022. 
 
You asked the Plan to pay for to recement crowns. You say that you disagree with the denial of dental services. 
The Plan denied your request. The Plan says recement crown (D2920) is 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 recement 
crowns on tooth #18 and 20 (D2920) provided on April 20, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core build up on tooth #8 (D2950) and a crown on tooth 
#8 (D2740). 
 
You asked the Plan to pre-approve core build up and a crown. You say that you were told these services were 
covered. 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 pre-approve core 
build up on tooth #8 (D2950) and a crown on tooth #8 (D2740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis - adult (D1110) provided April 26, 2022. 
 
You asked the Plan to pay for the dental cleaning. You say that you feel this service should be covered. The 
Plan denied your request. The Plan says you have exceeded the frequency limit for the requested 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. The Plan covers the dental 
cleaning once every 6 months.  
 
We looked at the file and Medicare rules. The Plan provided documentation showing that a dental cleaning was 
previously provided on November 4, 2022.  Based on this information, we decided that the Plan's frequency 
limit for coverage of the dental cleaning has been exceeded. Therefore, we decided that the Plan does not have 
to pay for the prophylaxis - adult (D1110) provided April 26, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants (D6010) for teeth #22 and #27 provided 
by an out-of-network provider. 
 
You asked the Plan to pre-approve dental implants. You say that you are in a lot of pain. You say that you need 
these services done. The Plan denied your request. The Plan says the requested 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 pre-approve 
dental implants (D6010) for teeth #22 and #27 provided by an out-of-network provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the pathology services provided on February 14, 2022. 
 
You asked the Plan to pay for the services provided. You say that the code is medically necessary and the 
correct diagnosis. The Plan denied your request. The Plan says that the service is not considered medically 
necessary. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the services by a contract provider. The file does not show that the Plan provided 
notice that the services would not be covered. Under Medicare rules, this means the services are considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the pathology services provided on 
February 14, 2022.  
 
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 pre-approve a maxillary partial denture (D5213). 
 
You asked the Plan to pre-approve the dental services. You say that you lost your dentures, and it is hard for 
you to eat. 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 November 8, 2018. 
Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visits provided from 
January 27, 2022, to March 25, 2022. 
 
You asked the Plan to waive the copayment for specialist office visits. You say that you dont agree with the 
charges. The Plan denied your request. The Plan says the copayments applied are correct. 
 
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 
copayment for per specialty care visit.  
 
You have been asked to pay $140 ($10 x 14 visits) copayment for specialist office visits. Specialist office visits 
fall within the Physician/Practitioner Services, Including Doctor's Office Visits 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 specialist office visits provided from January 27, 2022, to March 25, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Eliquis tablets. 
 
You asked the Plan to pre-approve self-administered drug. You say that the enrollee has had significant side-
effects from another drug. The Plan denied your request. The Plan says the denial of authorization for this drug 
is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's 
Medicare Part D prescription drug benefits. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Eliquis tablets.  
 
Benefits for self-administered drug 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you were fully functioning before admission and 
have gotten worse while waiting for authorization. You say that you are not ready to perform effectively on 
your own and need rehabilitation intervention. The Plan denied your request. The Plan says your ongoing 
skilled therapy and nursing needs can be provided at a lower level of care. 
 
  The Plan must follow Medicare rules. The rules say that 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 pre-approve 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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. While the medical record supports a need for physical or occupational therapy, there is no documented 
need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an epidural steroid injection (64483). 
 
You asked the Plan to pre-approve an epidural steroid injection. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you do not meet Medicare criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of an epidural steroid injection (64483) 
have been met. The Plan has made multiple attempts to obtain medical records from your provider with no 
response. Therefore, we decided that the Plan does not have to pre-approve an epidural steroid injection 
(64483).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for specialist office visit provided on 
December 1, 2021. 
 
You asked the Plan to waive the copayment for specialist office visit. You say that you were never charged this 
before so you shouldn't be now. The Plan denied your request. The Plan says the copayment applied is correct. 
 
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 $40 
copayment for each specialist office visits.  
 
You have been asked to pay $30 copayment which is less than the standard $40 copayment for specialist office 
visit. Specialist office visits fall within the Physician/Practitioner Services, Including Doctor's Office Visits 
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 specialist office visit provided on 
December 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you really need this shower chair. The Plan 
denied your request. The Plan says the requested item is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital care provided on May 12, 
2022. 
 
You asked the Plan to waive the copayment for inpatient hospital care. You say that you were not aware of the 
copayment, and you didn't even receive a room until late at night. The Plan denied your request. The Plan says 
the copayment applied is correct. 
 
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 $325 
copayment for per day for days 1 through 5.  
 
You have been asked to pay $325 copayment for inpatient hospital care. Inpatient hospital care falls within the 
Inpatient Hospital Care 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 inpatient 
hospital care provided on May 12, 2022.