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

 
We decided that the Plan does not have to pre-approve dental implants on tooth #2, 3, and 21 (D6010), surgical 
implant index (D6190), sinus augmentation (D7952), and deep sedation (D9222, D9223). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says dental implants (D6010), surgical implant index (D6190), sinus 
augmentation (D7952), and deep sedation (D9222, D9223) 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 
dental implants on tooth #2, 3, and 21 (D6010), surgical implant index (D6190), sinus augmentation (D7952), 
and deep sedation (D9222, D9223).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight endosteal implants (D6010 x8). 
 
You asked the Plan to pre-approve the endosteal implants. The Plan denied your request. The Plan says this 
service is not covered under your 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 eight 
endosteal implants (D6010 x8).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve diabetic supplies to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve diabetic supplies. You say that you would like to request reconsideration of 
the denied claim. The Plan denied your request. The Plan says the services you are requesting do not meet the 
requirements for approval. 
 
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 
diabetic supplies to be provided by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), 
and a filling (D2331) provided from March 1, 2022, through March 9, 2022. 
 
You asked the Plan to pay for the dental services. You say that you were not aware that the provider was out-
of-network. The Plan denied your request. The Plan says the dental services were received from an out-of-
network provider and are not covered by your supplemental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), teeth cleaning (D1110), and a filling (D2331) provided from 
March 1, 2022, through March 9, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a specialist office visit to be provided by an out-of-
network (OON) provider. 
 
You asked the Plan to pre-approve a specialist office visit. You say that you are diabetic, and this physician did 
a laser gap filling operation to your eyes. You also say that he is controlling the progress for the operations. 
You also say that this year you visited him on February 10, 2022, with the authorization referral effective from 
September 20, 2021, until September 20, 2022. You also say that this physician is in your provider net. The 
Plan denied your request. The Plan says the requested provider is not a network provider. The Plan also says 
that they will instead approve the office visits with a network provider. 
 
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 specialist office visit to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for an injection and office visit provided on 
February 16, 2022. 
 
You asked the Plan to waive the cost share for an injection and office visit. You say that you were told this 
would be covered. The Plan denied your request. The Plan says the cost share 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 20% 
coinsurance for Medicare covered Part B drugs provided at a specialists office and a $25 copayment for the 
office visit.  
 
 You have been asked to pay $246.80 which is 20% of the allowed amount for an injection. The allowed amount 
is $1,234 (20% x $1,234= $246.80).  You have also been asked to pay $25 copayment for the office visit 
totaling an amount of $271.80. The injection falls within the Medicare Part B Prescription Drugs benefit 
category. The specialist office visit falls 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 cost share for an injection and office visit 
provided on February 16, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental implants on tooth #9, 30, and 31 (D6010), 
prefabricated abutments on tooth #9, 30, and 31 (D6056), and abutment supported crowns on tooth #9, 30, and 
31 (D6062). 
 
You asked the Plan to pre-approve the dental services. You say that these services are medically necessary, and 
you cannot afford them. The Plan denied your request. The Plan says dental implants (D6010), prefabricated 
abutments (D6056), and abutment supported crowns (D6062) 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 
dental implants on tooth #9, 30, and 31 (D6010), prefabricated abutments on tooth #9, 30, and 31 (D6056), and 
abutment supported crowns on tooth #9, 30, and 31 (D6062).
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. 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 6, 2019. Therefore, 
we decided that the Plan does not have to pre-approve a maxillary partial denture (D5213).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the scaling and root planing (D4341 x 2) and gingival 
irrigation (D4921 x 2) provided on April 4, 2022, by the out-of-network provider. 
 
You asked the Plan to pay more for the dental services. You say that you were initially quoted for out-of-
pocket charges of $325. You say that you received an additional bill of $314. You also say that you cannot 
afford to pay this. The Plan denied your request. The Plan says you are responsible for any charged amount 
above the Plans cost-sharing amount when your services are received from an out-of-network provider. The 
Plan says that the $325 that you paid was for a previous balance. The Plan says the remaining balance is $314. 
The Plan also says gingival irrigation is not listed as a covered 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. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans payment for the scaling and root planing. This cost sharing is a contractual obligation you agreed to pay when 
you enrolled in the Plan. Additionally, gingival irrigation is not listed as a covered service. Therefore, we 
decided that the Plan does not have to pay more for the scaling and root planing (D4341 x 2) and gingival 
irrigation (D4921 x 2) provided on April 4, 2022, by the out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for urgent care services provided on June 2, 
2022. 
 
You asked the Plan to waive the copayment for urgent care services. You say that you didn't receive any 
treatment so it should be covered. The Plan denied your request. The Plan says the copayment should be 
covered. 
 
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 $65 
copayment for Medicare covered urgently needed care services.  
 
You have been asked to pay $65 copayment for urgent care services. Urgent care services fall within the 
Urgently Needed 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 urgent care 
services provided on June 2, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that additional clinical information is 
included for review. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient 
acute care and is currently unstable for transfer to an LTACH. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee was admitted to the acute care hospital with colitis with sepsis 
complicated by stenosis of celiac artery and rhabdomyolysis requiring intravenous heparin, antibiotics, and 
fluids. The enrollee had gastrointestinal anemia, diarrhea, and persistent leukocytosis. The enrollee appears to 
still be somewhat unstable now and requires additional short-term acute care services that can safely be 
administered at the current facility until more stable and appropriate for a lower level of care. The enrollee is 
receiving appropriate care at the present setting. The enrollee does not require services at the LTACH that are 
not available at the current facility where they are currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve the LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a crown on tooth #19 (D2740) provided on 
April 14, 2022. 
 
You asked the Plan to waive the cost share for a crown. You say that you disagree with the cost share amount. 
The Plan denied your request. The Plan says that your dental allowance has been exhausted. 
 
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 have a $2,000 
allowance for supplemental preventive and comprehensive dental services. 
 
The record shows your dental allowance was met during the processing of this claim. You have been asked to 
pay $1,514 for a crown. A crown falls within the Dental 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 cost share for a crown on tooth #19 (D2740) provided on April 14, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a complete 
mandibular denture (D5120). 
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says your 
benefit for the requested items or services 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 items or services was exhausted on date of service December 3, 2020. 
Therefore, we decided that the Plan does not have to pre-approve a complete maxillary denture (D5110) and a 
complete mandibular denture (D5120).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that this procedure is medically reasonable 
and necessary. The Plan denied your request. The Plan says medical studies have not proven that this procedure 
is helpful for treatment of your health problem. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed to show safety and 
efficacy when used as bone graft material. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for chiropractor visits provided on February 7, 
2022, and March 7, 2022. 
 
You asked the Plan to waive the copayment for chiropractor visits. You say that this should be covered. 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 $20 
copayment for each Medicare covered visit.  
 
You have been asked to pay $40 ($20 x 2 visits) copayment for chiropractor visits. Chiropractor visits fall 
within the Chiropractic 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 
chiropractor visits provided on February 7, 2022, and March 7, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an ultrasound provided on May 13, 2022. 
 
You asked the Plan to waive the copayment for an ultrasound. You say that you thought this was covered under 
the same copayment as the mammogram. 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 $30 
copayment for specialty physician for other Medicare covered outpatient diagnostic tests.  
 
You have been asked to pay $30 copayment for an ultrasound. Ultrasounds 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 an ultrasound provided on May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox (J0585) injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says this request is not considered to be medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injections. Our reviewer says that 
the requested injections are not medically reasonable or necessary. Our physician reviewer found the record 
indicates that the enrollee has bilateral temporomandibular joint disorder.  The noted diagnosis is not an 
enumerated condition for which coverage is available under the rules. The elements of the coverage criteria are 
not satisfied.  
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Botox (J0585) injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve accidental dental services. 
 
You asked the Plan to pre-approve accidental dental services. You say that you know you do not have dental 
coverage, but feel these services should be covered under your medical plan. The Plan denied your request. The 
Plan says you have not enrolled in a comprehensive dental policy. The Plan also says that these services are not 
covered. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve 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 pre-approve accidental dental 
services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ER visit provided on April 1, 2022. 
 
You asked the Plan to waive the copayment for ER visit. You say that this was your second time back to the 
ER for the same issue so it should be covered. 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 $90 
copayment for each emergency room visit.  
 
You have been asked to pay $90 copayment for ER visit. ER visits fall 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 April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 15, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 70450 is bundled into payment for code 70496. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 
is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 15, 2022.