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

 
We decided that the Plan does not have to waive the copayment for emergency room services on July 08, 2022, 
to July 09, 2022. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you want to appeal the 
amount being charged. 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 
copayment for emergency care worldwide. Emergency care refers to services that are furnished by a provider 
qualified to furnish emergency services, and needed to evaluate or stabilize an emergency medical condition. 
 
You have been asked to pay a $50 copayment for emergency room services. This item/service falls within the 
Emergency 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 emergency room 
services on July 08, 2022, to July 09, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a surgical extraction (D7999) for tooth #30. 
 
You asked the Plan to pre-approve the dental service. You say that your tooth cannot be pulled, and you need 
oral surgery. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because surgical extractions 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 a 
surgical extraction (D7999) for tooth #30.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the surgical placement of an endosteal implant (D6010). 
 
You asked the Plan to pre-approve the dental services. You say that your provider told you this service needs to 
be done. The Plan denied your request. The Plan says this service is not a covered benefit under your dental 
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 placement of an endosteal implant (D6010).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided from July 28, 2022. 
 
You asked the Plan to waive the copayment for CT scan. You say that you disagree with 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 $300 
copayment for in-network outpatient hospital services/advanced imaging services.  
 
You have been asked to pay $300 copayment for CT scan. This item/service falls within the in-network 
outpatient hospital services/advanced imaging 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 a computed tomography (CT) scan provided from July 28, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a 3rd level facet joint injection. 
 
You asked the Plan to pre-approve a 3rd level facet joint injection. You say that the services are necessary. The 
Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been 
met. 
 
The Plan follows Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, are 
allowed per session per spine region. 
 
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 a 3rd level facet joint injection. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found the request for a 
third level exceeds utilization limits; only 2 levels bilaterally may be performed. Therefore, the request for a 
third level is deemed not medically reasonable or 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 a 3rd level facet joint injection have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a 3rd level facet joint injection.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor kit. 
 
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 the criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not treat with insulin three or more times per day or use an insulin pump. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) sensor kit.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve two surgical accesses to implant bodies (D6011 x2) and 
two bone grafts at time of implant placement (D6104 x2). 
 
You asked the Plan to pre-approve the surgical accesses to implant bodies and bone grafts. The Plan denied 
your request. The Plan says these services are not covered under the enrollee's benefit 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 two 
surgical accesses to implant bodies (D6011 x2) and two bone grafts at time of implant placement (D6104 x2).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Medicare Part B drugs provided on May 
10, 2022. 
 
You asked the Plan to waive the coinsurance for Medicare Part B drugs. 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 a 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay a 20% coinsurance for Medicare Part B drugs. The total allowed amount for the 
Medicare Part B drugs is $3,666. The total amount you are being asked to pay is $733.20 ($3,666 x 20% = 
$733.20). 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 Medicare Part B drugs provided on May 10, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for telehealth visit provided on December 30, 2021, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for telehealth visit. 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 this chapter). In most cases, care the enrollee receives from an out-of-network 
provider (a provider who is not part of our plans network) will not be 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for telehealth visit provided on December 30, 2021, 
by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for regadenoson injections provided on June 
15, 2022. 
 
You asked the Plan to waive the coinsurance for regadenoson injections. You say that you already paid a copay 
at the time of the service, and you don't understand why you're being asked to pay extra. 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 $49.20 coinsurance for regadenoson injections. This item/service falls within the 
Medicare Part B prescription 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 
regadenoson injections provided on June 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facet injection; third and any additional level (64495). 
 
You asked the Plan to pre-approve a facet joint injection, third level. You say that the requested injections are 
medically necessary. The Plan denied your request. The Plan says the requested injection is not medically 
necessary. 
 
The Plan follows Medicare rules. Medicare rules say that facet joint injections at one to two levels, either 
unilateral or bilateral, are allowed per session per spine region. 
 
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 a facet joint injection, third level. Our 
reviewer says that the requested facet joint injection, third level, is not medically necessary. Our physician 
reviewer found only two levels are allowed per session. Therefore, the reviewer found that an injection at a 
third level 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 a facet joint injection, third level have not been met. Therefore, we decided that 
the Plan does not have to pre-approve facet injection; third and any additional level (64495).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided by a participating provider on 
August 4, 2022. 
 
You asked the Plan to pay for the dental services. You say that you did not think that cleanings had a maximum 
limit. 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 February 28, 2022. 
Therefore, we decided that the Plan does not have to pay for dental services provided by a participating 
provider on August 4, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on August 18, 2022. 
 
You asked the Plan to waive the copayment for ER visit. 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 $90 
copayment for Emergency care. 
 
You have been asked to pay a $90 copayment for ER visit. This item/service falls within the Emergency 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 ER visit provided on August 18, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oral evaluation (D0150) to be provided by an 
endodontist. 
 
You asked the Plan to pre-approve the oral evaluation (D0150). You say that you are unable to eat normal food 
and you need the evaluation by an endodontist. The Plan denied your request. The Plan says the service is not a 
covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the oral evaluation (D0150) is not 
among those covered under this benefit when provided by an endodontist. Therefore, we decided that the Plan 
does not have to pre-approve the oral evaluation (D0150) to be provided by an endodontist.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for crowns on tooth #28 and 29 (D2740) and core build up on 
tooth #28 and 29 (D2950) provided on July 25, 2022. 
 
You asked the Plan to pay for crowns and core build up. You say that you had a predetermination done 
approving these services. The Plan denied your request. The Plan says that crowns (D2740) and core build up 
(D2950) are not covered by your supplemental 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 crowns on 
tooth #28 and 29 (D2740) and core build up on tooth #28 and 29 (D2950) provided on July 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services provided on July 12, 2022, by an out-of-
network (OON) provider. 
 
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 service is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental 
services provided on July 12, 2022, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the core build-up (D2950) and the endodontic therapy 
(D3320) provided by an out-of-network provider from August 10, 2022, to August 18, 2022. 
 
You asked the Plan to pay for the core build-up (D2950) and the endodontic therapy (D3320). You say that you 
went to a new dentist, and you were told that the office accepted your insurance. The Plan denied your request. 
The Plan says the 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 the core 
build-up (D2950) and the endodontic therapy (D3320) provided by an out-of-network provider from August 
10, 2022, to August 18, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical extraction (D7210) provided on July 25, 2022, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the surgical extraction. You say that you were told by the office that your 
insurance would cover the extraction. The Plan denied your request. The Plan says the dental service was 
received from an OON provider and is 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 service from an OON provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, the requested service is not covered under this benefit when 
received from an OON provider. Therefore, we decided that the Plan does not have to pay for the surgical 
extraction (D7210) provided on July 25, 2022, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202), x-ray exam of the lumbar spine 
(72100), and the x-ray exam of the spine, single view (72020) provided from April 6, 2022, through June 6, 
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 by the 
Plan or by Medicare. 
 
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 office visit (99202), x-ray exam of the lumbar spine (72100), and the 
x-ray exam of the spine, single view (72020) provided from April 6, 2022, through June 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a prefabricated abutment (D6056), an endosteal implant 
(D6010), and a reline complete mandibular and maxillary denture (D5751 and D5750). 
 
You asked the Plan to pre-approve a prefabricated abutment, an endosteal implant, and a reline complete 
mandibular and maxillary denture. You say that you would like the Plan to approve these services. 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 pre-approve a 
prefabricated abutment (D6056), an endosteal implant (D6010), and a reline complete mandibular and 
maxillary denture (D5751 and D5750).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on July 14, 2022. 
 
You asked the Plan to pay for the prophylaxis. You say that it is your understanding that you are allowed one 
cleaning every four months. The Plan denied your request. The Plan says your benefit for the requested service 
had already been exhausted for the six-month time period. 
 
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 service was exhausted on date of service March 8, 2022, for the six-month 
time period. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on 
July 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services on August 8, 2022. 
 
You asked the Plan to pay for the dental services. You say that you would like to request reconsideration for 
payment. 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 August 8, 2022. 
Therefore, we decided that the Plan does not have to pay for the dental services on August 8, 2022.