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

 
We decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided 
on December 06, 2022. 
 
You asked the Plan to waive the coinsurance for a Medicare Part B drug injection. You say that you are unable 
to afford the cost share applied. The Plan denied your request. The Plan says this cost sharing was charged 
correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B Prescription Drugs. 
 
You have been asked to pay 20% coinsurance for a Medicare Part B drug injection. 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. The total coinsurance you owe is $604.80, which is 20% of the 
cost share applied for a Medicare Part B drug injection ($3,024 allowed x 20% = $604.80). Therefore, we 
decided that the Plan does not have to waive the coinsurance for a Medicare Part B drug injection provided on 
December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (D5225), and 
mandibular partial denture -flexible base (D5226). 
 
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 August 27, 2020. 
Therefore, we decided that the Plan does not have to pre-approve maxillary partial denture - flexible base (D5225), and mandibular partial denture -flexible base (D5226).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the knee replacement surgery with a Mako Robotic Arm 
at an out-of-network provider. 
 
You asked the Plan to pre-approve the knee replacement surgery with a Mako Robotic Arm . You say that the 
out-of-network provider has the advanced technology that is used to perform the knee replacement surgery by 
using a Mako Robotic Arm that is less invasive, more precise, and less rehabilitation. The Plan denied your 
request. The Plan says the Mako Robotic Arm is not medically necessary. The Plan says the use of robotics in 
routine total knee arthroplasty has not been shown to significantly improve clinical outcomes. 
 
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 knee replacement surgery with a 
Mako Robotic Arm. Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. Our physician reviewer found you are being treated for osteoarthritis of the left knee. 
You presented with chronic left knee pain. There is no large volume, long-term/high-quality clinical studies 
confirm the clinical benefits of computer-assisted surgery over standard surgical approaches in total knee 
arthroplasty. The requesting provider did not include a detailed rationale as to why MAKOplasty is needed 
over the standard surgical approach in this clinical scenario. There is no compelling rationale or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
total knee replacement with the use of Mako Robotic Arm is 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 the knee replacement surgery with a Mako Robotic Arm have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the knee replacement surgery with a Mako 
Robotic Arm at an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve core buildup, including any pins when required tooth 
#30  (D2950). 
 
You asked the Plan to pre-approve the core buildup, including any pins when required. You say that the 
enrollee needs the requested D2950 core buildup. You also ask to please review the submitted intra-oral 
picture. The Plan denied your request. The Plan says there is no coverage for D2950 core buildup including any 
pins, when required. 
 
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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve core 
buildup, including any pins when required tooth #30  (D2950).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve labial veneers (porcelain laminate) - indirect (D2962). 
 
You asked the Plan to pre-approve the labial veneers. The Plan denied your request. The Plan says this service 
is not covered on your 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve labial 
veneers (porcelain laminate) - indirect (D2962).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic - porcelain/ceramic (D6245), and retainer crown 
- porcelain/ceramic (D6740). 
 
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. Therefore, we decided that the Plan does 
not have to pre-approve pontic - porcelain/ceramic (D6245), and retainer crown - porcelain/ceramic (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic tooth #05 (D62450), and retainer crown tooth 
#06 and #04 (D6740). 
 
You asked the Plan to pre-approve pontic and retainer crown. You say that this should be covered. The Plan 
denied your request. The Plan says this is not 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. 
 
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 
pontic tooth #05 (D62450), and retainer crown tooth #06 and #04 (D6740).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve dental surface scan  direct (D0801), onlay -
porcelain/ceramic - four or more surfaces (D2644) and a crown - resin-based composite (D2710). 
 
You asked the Plan to pre-approve these dental services. You say that this should be covered. The Plan denied 
your request. The Plan says this is not 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. 
 
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 surface scan  direct (D0801), onlay -porcelain/ceramic - four or more surfaces (D2644) and a crown - resin-based composite (D2710).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on April 20, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you are 
unable to afford the copayment applied and would like the Plan to pay it. 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 $95 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $95 copayment for a magnetic resonance imaging (MRI). This item/service falls 
within the outpatient diagnostic tests 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 
magnetic resonance imaging (MRI) provided on April 20, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve fitting and placing a post in a tooth for tooth 27 
(D3950); and a rubber dam for tooth 27 (D3910). 
 
You asked the Plan to pre-approve fitting and placing a post in a tooth and a rubber dam for tooth 27. You say 
that this should be covered. The Plan denied your request. The Plan says this is not 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. 
 
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 
fitting and placing a post in a tooth for tooth 27 (D3950); and a rubber dam for tooth 27 (D3910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for inpatient hospital stay on March 13, 2023, 
to March 21, 2023. 
 
You asked the Plan to waive the copayment for inpatient hospital stay. 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 $335 
copayment per day for days 1-5, $0 copayment per day for days 6 and beyond for inpatient hospital care. 
Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital 
services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctors order. 
The day before you are discharged is your last inpatient day. 5 x $335 = $1,675. Therefore, results in the total 
cost sharing amount of $1,675. 
 
You have been asked to pay a $335 copayment per day for inpatient hospital stay. This item/service 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 stay on March 13, 2023, to March 21, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for low osmolar contrast material, 300-399 mg/ml iodine 
concentration, per ml rendered on December 6, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Healthcare Common Procedure Coding System (HCPCS) code Q9967 (3 units) remains not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of Healthcare Common Procedure Coding System (HCPCS) code 
Q9967 is "Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml." 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the enrollee had ultiple nerve 
blocks under fluoroscopic guidance which required contrast injection for guidance on December 6, 2022. No 
volume of used contrast was indicated in the procedure report. In addition, it would not be reasonable to 
assume a volume of 300 ml would have been necessary or even safe for the dictated procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml rendered on 
December 6, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with 
resin denture bases (D5213), and mandibular partial denture - cast metal framework with resin denture bases  
(D5214). 
 
You asked the Plan to pre-approve the maxillary partial and mandibular partial dentures. You say that you have 
been utilizing a broken upper denture and cannot afford to purchase a new set with a fixed income. You also 
say that the provider advises that you need these dentures. The Plan denied your request. The Plan says there is 
no coverage for upper and lower dentures (D5213 & D5214). 
 
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 services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a maxillary 
partial denture - cast metal framework with resin denture bases (D5213), and mandibular partial denture - cast 
metal framework with resin denture bases  (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a porcelain/ceramic crown (D6058) for tooth number 4, 
a bone graft at time of implant placement (D6104) for tooth number 4, a custom fabricated abutment (D6057) 
for tooth number 4, fluoride treatment (D1206), gingival irrigation (D4921) for all quadrants, surgical access to 
an implant body (D6011) for tooth number 4, an endosteal implant (D6010) for tooth number 4, a 
porcelain/ceramic pontic (D6245) for tooth number 13, a post-operative office visit (D0171), scaling (D4346), 
and oral hygiene instructions (D1330). 
 
You asked the Plan to pre-approve a porcelain/ceramic crown (D6058) for tooth number 4, bone graft at time 
of implant placement (D6104) for tooth number 4, a custom fabricated abutment (D6057) for tooth number 4, 
fluoride treatment (D1206), gingival irrigation (D4921) for all quadrants, surgical access to an implant body 
(D6011) for tooth number 4, an endosteal implant (D6010) for tooth number 4, a porcelain/ceramic pontic 
(D6245) for tooth number 13, a post-operative office visit (D0171), scaling (D4346), and oral hygiene 
instructions (D1330). You say that you are appealing with supporting records. The Plan denied your request. 
The Plan says these services are not covered in your dental 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 pre-approve a 
porcelain/ceramic crown (D6058) for tooth number 4, a bone graft at time of implant placement (D6104) for 
tooth number 4, a custom fabricated abutment (D6057) for tooth number 4, fluoride treatment (D1206), 
gingival irrigation (D4921) for all quadrants, surgical access to an implant body (D6011) for tooth number 4, 
an endosteal implant (D6010) for tooth number 4, a porcelain/ceramic pontic (D6245) for tooth number 13, a 
post-operative office visit (D0171), scaling (D4346), and oral hygiene instructions (D1330).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a fixed partial denture sectioning (D9120). 
 
You asked the Plan to pre-approve the fixed partial denture sectioning. The Plan denied your request. The Plan 
says this service is not covered  in your dental 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a fixed 
partial denture sectioning (D9120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transportation (99499) from a non-contracted provider. 
 
You asked the Plan to pre-approve transportation (99499) from a non-contracted provider. You say that you 
need additional hours for this transportation service. The Plan denied your request. The Plan says this request is 
for a provider who is not a participating provider of your health Plan. 
 
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 routine transportation when the provider is in-network.  
 
We looked at your request, the records in the case file, and the rules. The Plan rules say that members of the 
Plan must use network providers to get medical care and services. The record shows this provider is not in-
network. Based on this information, we decided that the Plans rules for coverage of routine transportation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve transportation (99499) from a 
non-contracted provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on April 04, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that you were 
advised this service would be covered in full. 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 $350 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $350 copayment for a magnetic resonance imaging (MRI). This item/service 
falls within the outpatient diagnostic tests 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 magnetic resonance imaging (MRI) provided on April 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical placement of implant body: endosteal implant 
(D6010) Tooth #4. 
 
You asked the Plan to pre-approve the dental services. You say that your provider says you need the requested 
service to complete your dental work. 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. This benefit includes the 
requested item or service but is limited to implants: up to two implants covered per year, or up to four implants 
covered per year for edentulous patients, covered one per tooth per life. Crowns on implants are covered one 
per tooth every five years with appropriate justification. Implant services will only be covered when performed 
by a certified provider. All abutments are covered one per tooth per life. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you have been pre-approved for surgical placement of implant body: endosteal implant (D6010) Tooth 
#3 from June 16, 2023, to September 7, 2023, and your Plan paid for custom fabricated abutment - includes 
placement (D6057) and abutment supported porcelain/ceramic crow (D6058) were paid for Tooth #29 on date 
of service June 12, 2023. Therefore, the benefit has been exhausted. Therefore, we decided that the Plan does 
not have to pre-approve surgical placement of implant body: endosteal implant (D6010) Tooth #4.