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

 
We decided that the Plan does not have to pre-approve a retrograde filling and surgical repair of a root (D3471, 
D3430). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve a 
retrograde filling and surgical repair of a root (D3471, D3430).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a dental crown. 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial, and they are medically necessary. 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 pre-approve a 
dental crown.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ultrasound provided on August 19, 2022. 
 
You asked the Plan to waive the copayment for ultrasound. You say that this should be covered. 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 $155 
copayment for Radiological diagnostic services. 
 
You have been asked to pay a $155 copayment for ultrasound. This item/service falls within the Radiological 
diagnostic 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. You have been asked to pay $97.40 which is less than the standard $155 copayment for an 
ultrasound. Therefore, we decided that the Plan does not have to waive the copayment for ultrasound provided 
on August 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical placement of the implant body (D6010), a bone 
graft (D6104), the removal of impacted tooth (D7230), and unspecified oral surgery procedure (D9999) for 
tooth #17 and #19 provided on July 5, 2021, and July 9, 2021. 
 
You asked the Plan to pay for the dental services. You say that the dental procedures were medically necessary. 
The Plan denied your request. The Plan says the services rendered are not covered by Medicare or the Plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
  The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the surgical placement of the 
implant body (D6010), a bone graft (D6104), the removal of impacted tooth (D7230), and unspecified oral 
surgery procedure (D9999) for tooth #17 and #19 provided on July 5, 2021, and July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for core buildup (D2950) for tooth #2, #8, and #10 provided on 
January 18, 2022. 
 
You asked the Plan to pay for the dental services. You say that the crowns that were done did not match your 
teeth. The Plan denied your request. The Plan says your maximum dental benefit for the year has already been 
exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on the date of service of January 18, 2022. 
On January 18, 2022, the Plan paid $3,500 for the dental services; therefore, the annual dental benefit 
maximum was exhausted. Therefore, we decided that the Plan does not have to pay for core buildup (D2950) 
for tooth #2, #8, and #10 provided on January 18, 2022.  
 Your complaint about the provider not matching your teeth 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the initial hospital care (99223-57) provided on December 1, 
2021. 
 
You asked the Plan to pay for the initial hospital care. You say that the medical records support the use of 
modifier 57 with code 99223. The Plan denied your request. The Plan says the medical records do not support 
the use of modifier 57 with code 99223.  
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 initial hospital care. Our physician 
reviewer found CPT code 99223 Initial Hospital Care with modifier 57 decision for surgery in addition to 
treatment of fracture. Documentation submitted was reviewed and does not meet criteria. Evaluation and 
management record does not support modifier 57, as no initial decision for service was documented in the 
procedure. In this case, there is insufficient documentation to confirm the evaluation and management service 
provided, resulted in the need for surgery. 
 
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 initial hospital care have not been met. Therefore, we decided that the Plan 
does not have to pay for the initial hospital care (99223-57) provided on December 1, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom abutments (D6057) and abutment supported to 
metal crown (D6059) for tooth #29 and #30. 
 
You asked the Plan to pre-approve the dental services.. You say that you were previously approved for the 
requested dental services. The Plan denied your request. The Plan says the denial of authorization for these 
services is correct, because dental implants and all associated services 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 pre-approve 
custom abutments (D6057) and abutment supported to metal crown (D6059) for tooth #29 and #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve  core buildup (D2950) and a crown (D2740). 
 
You asked the Plan to pre-approve the dental services. You say that this should be covered. 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 June 25, 2019. Therefore, 
we decided that the Plan does not have to pre-approve  core buildup (D2950) and a crown (D2740).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the administration of influenza virus vaccine provided on 
October 7, 2022. 
 
You asked the Plan to pay for the administration of influenza virus vaccine. You say that the enrollees flu shot 
was not related to the diagnosis for the hospice episode, therefore, the flu vaccine is payable. The Plan denied 
your request. The Plan says Original Medicare is responsible for payment.  
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the administration of influenza virus vaccine provided on 
October 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for general health panel testing provided on August 08, 2022. 
 
You asked the Plan to pay for general health panel testing. 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 general health panel 
testing provided on August 08, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent hospital care, per day (99232) and the 
hospital discharge day management (99239) rendered by the out-of-network (OON) provider on June 17, 2022, 
and June 18, 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 the services were rendered by an out-of-
network provider, without prior authorization. 
 
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 in this case is not a network provider with the Plan. The Plan had network providers available 
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue. 
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the subsequent hospital care, per day (99232) and the hospital discharge day 
management (99239) rendered by the out-of-network (OON) provider on June 17, 2022, and June 18, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for the diagnostic services. We decided that the Plan 
does not have to waive the copayment for the skilled nursing facility services.  
 
You asked the Plan to waive the copayment for radiologic examination, chest, two views, frontal and lateral 
(71046) and skilled nursing facility services provided August 2, 2022, to August 31, 2022.. You say that you 
are being charged $425 for the chest x-ray, which was done as a basic requirement before admission. You were 
assured all through the rehab admission process that your stay would be entirely paid by the Plan. The Plan 
says that the cost share was applied correctly. 
 
We decided that the Plan has to waive the copayment for the diagnostic services.  
 
You were referred for the diagnostic services by a contract provider. The file does not show that the Plan 
provided notice that the diagnostic services would not be covered. Under Medicare rules, this means the 
diagnostic service is considered approved by the Plan. Therefore, we decided that the Plan has to waive the 
copayment for the diagnostic services.  
 
We also decided that the Plan does not have to waive the copayment for the skilled nursing facility 
services. 
 
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 $0 
copayment per day for days 1-20 and $140 copayment per day for days 21-40 for the SNF stay. 
 
You have been asked to pay $980 ($140 x 7 days) for the SNF stay. This item/service falls within the Skilled 
nursing facility (SNF) 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 the skilled nursing facility 
services. 
 
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 an occlusal guard (D9944) 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve an 
occlusal guard (D9944)
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a retainer crown and pontic (D6751, D6241). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says 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 pre-approve a 
retainer crown and pontic (D6751, D6241).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair (E0240). 
 
You asked the Plan to pre-approve a shower chair. You say that the items should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says this 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 (E0240).
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 the enrollee is medically stable in home setting and no active medical comorbidities 
are specified thus the complexity of the enrollee's documented nursing, medical and rehabilitation needs would 
not be expected to require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 
care. IRF criteria not met.  
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve guided tissue regeneration - resorbable barrier, per site 
(D4266), bone graft at time of implant placement (D6104), and surgical access to an implant body (D6011) all 
for tooth #11. 
 
You asked the Plan to pre-approve the dental services.. You say that you are asking the plan to review and 
reconsider coverage for codes D4266, D6011 and D6104. 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 
guided tissue regeneration - resorbable barrier, per site (D4266), bone graft at time of implant placement 
(D6104), and surgical access to an implant body (D6011) all for tooth #11.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Tiagabine HCl. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says self-administered drugs are not covered. 
 
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 Tiagabine HCl.  
 
Benefits for these services 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 pre-approve dentures (D5110, D5214). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as you 
disagree with the denial. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service March 12, 2021. 
Therefore, we decided that the Plan does not have to pre-approve dentures (D5110, D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the resin-based composite - two surfaces, posterior (D2392) 
provided on March 23, 2022. 
 
You asked the Plan to pay for the resin-based composite - two surfaces, posterior (D2392). You say that you do 
not recall having restorative dental services completed on the date in question. The Plan denied your request. 
The Plan says this service is 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 pay for the resin-
based composite - two surfaces, posterior (D2392) provided on March 23, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for x-ray provided on August 25, 2022. 
 
You asked the Plan to waive the copayment for x-ray. You say that this should be covered. 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 $110 
copayment for Basic radiological services. 
 
You have been asked to pay a $110 copayment for x-ray. This item/service falls within the Basic radiological 
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. You have been asked to pay $76.96 which is less than the standard $110 copayment for an x-ray. 
Therefore, we decided that the Plan does not have to waive the copayment for x-ray provided on August 25, 
2022.