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

 
We decided that the Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the 
cervical spine provided on May 04, 2023. 
 
You asked the Plan to waive the copayment for magnetic resonance imaging (MRI) of the cervical spine. You 
say that nothing was paid by insurance for this service. 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 $250 
copayment for advanced imaging services at an outpatient hospital. 
 
You have been asked to pay a $250 copayment for magnetic resonance imaging (MRI) of the cervical spine. 
This item/service falls within the advanced imaging services at an outpatient hospital 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. However, since the 
allowed amount is less than the standard copayment, you only owe $222.17. Therefore, we decided that the 
Plan does not have to waive the copayment for magnetic resonance imaging (MRI) of the cervical spine 
provided on May 04, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the unlisted procedure, of the dentoalveolar structures 
(41899) and the anesthesia for intraoral procedures, including biopsy (00170). 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says the requested dental services 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 pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees 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 the 
unlisted procedure, of the dentoalveolar structures (41899) and the anesthesia for intraoral procedures, 
including biopsy (00170).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Trelegy. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee has tried and failed both Advair 
and Spiriva. The Plan denied your request. The Plan says the medication is not covered as a medical benefit 
under the Plan. 
 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 Trelegy.  
 
Benefits for the medication 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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 01, 2022, to 
January 12, 2022. 
 
You asked the Plan to pay for skilled nursing facility. You say that the records provided support the services. 
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 skilled nursing facility 
provided on January 01, 2022, to January 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services. 
 
You asked the Plan to pre-approve the dental services. You say that you would like to request reconsideration 
of the denied claim. 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 December 22, 2021. 
Therefore, we decided that the Plan does not have to pre-approve the dental services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the lumbar spine. 
 
You asked the Plan to pre-approve the MRI. You say that you had x-rays done that showed a possible broken 
bone. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan follows Medicare rules. Medicare rules say that enrollee's must meet the criteria list in the LCD 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 the MRI. Our reviewer says that the 
service is not medically necessary. Our physician reviewer found you have bilateral radicular symptoms. A 
computed tomography (CT) of the lumbar spine was approved on June 28, 2023, with no report in the records 
indicating this has been done and no explanation given why MRI is medically necessary. You are 
neurologically intact, and no clinical red flag is given. 
 
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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation - established patient (D0120), and 
prophylaxis - adult (D1110) provided on February 22, 2023. 
 
You asked the Plan to pay for the periodic oral evaluation and prophylaxis - adult. You say that you have been 
getting 2 cleanings per year for many years. You also say that your insurance has not changed and the plan paid 
all the past charges except this last one. The Plan denied your request. The Plan says your benefit for the 
periodic oral evaluation and prophylaxis  adult 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 periodic oral evaluation and prophylaxis  adult was exhausted on date of service 
October 17, 2022. Therefore, we decided that the Plan does not have to pay for a periodic oral evaluation - 
established patient (D0120), and prophylaxis - adult (D1110) provided on February 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for free soft tissue graft procedure (D4277) provided on March 
27, 2023. 
 
You asked the Plan to pay for free soft tissue graft procedure. 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 pay for free soft 
tissue graft procedure (D4277) provided on March 27, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided from April 14, 2023, to 
April 19, 2023. 
 
You asked the Plan to pay for the medication. You say that the medications should be covered. The Plan denied 
your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
  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 pay for self-administered drugs provided 
from April 14, 2023, to April 19, 2023.  
 
Benefits for the medication 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on May 02, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that the service 
was routine and a copayment should not apply. 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 $250 
copayment for outpatient diagnostic tests. 
 
You have been asked to pay a $250 copayment for a computed tomography (CT) scan. 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. The total you owe is $105.57, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on May 02, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a problem focused limited oral evaluation (D0140) 
provided on April 24, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you had no other choice but to go to this 
out-of-group provider. You also say this was an emergency situation. 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.  
 
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. 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 pay more for a problem focused limited oral evaluation 
(D0140) provided on April 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 2 dimensional (2D) oral/facial photographic images (D0350), 
a 3 dimensional (3D) dental surface scan (D0801), and an intraoral - periapical each additional radiographic 
image (D0230) provided on April 11, 2023. 
 
  You asked the Plan to pay for 2 dimensional (2D) oral/facial photographic images (D0350), a 3 dimensional 
(3D) dental surface scan (D0801), and an intraoral - periapical each additional radiographic image (D0230). 
You say that the provider took you back for x-rays before the examination, and did not tell you anything about 
any charges that were not covered by the Plan. The Plan denied your request. The Plan says 2 dimensional (2D) 
oral/facial photographic images (D0350) and 3 dimensional (3D) dental surface scans (D0801) are not covered 
under this benefit. The Plan also says that your benefit for an intraoral - periapical each additional radiographic 
image (D0230) has ready 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, 2 dimensional (2D) oral/facial 
photographic images (D0350), and a 3 dimensional (3D) dental surface scan (D0801) are not among those 
covered under this benefit. The record shows your benefit for an intraoral - periapical each additional 
radiographic image (D0230) was exhausted on date of service April 11, 2023. Therefore, we decided that the 
Plan does not have to pay for 2 dimensional (2D) oral/facial photographic images (D0350), a 3 dimensional 
(3D) dental surface scan (D0801), and an intraoral - periapical each additional radiographic image (D0230) 
provided on April 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a complete maxillary denture (D5110) and the repair of a 
broken maxillary base (D5512) provided on January 13, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were informed that you were covered. 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 complete maxillary denture (D5110) and the repair of a broken maxillary base (D5512) provided 
on January 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve physical therapy to be provided by an OON provider.  
 
You asked the Plan to pre-approve physical therapy. You say that you want to see an out-of-network provider, 
but you are requesting in-network payment level. The Plan denied your request. The Plan says the service can 
be provided by an in-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 
physical therapy to be provided by an OON provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the scaling in presence of gingival inflammation (D4346) 
provided on April 19, 2023. 
 
You asked the Plan to pay for the dental service. You say that you had a cleaning which is a prophylaxis and 
the service should be covered. The Plan denied your request. The Plan says the denial of payment for this 
service is correct, because the scaling in presence of gingival inflammation is 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 item or service is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
scaling in presence of gingival inflammation (D4346) provided on April 19, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) 
provided on May 2, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service January 24, 2023.   
 
 
Specifically, the Plans contract states that one set of bitewing x-rays are covered every 2 calendar years or one 
set of periapical films are covered every 2 calendar years. You previously received bitewing x-rays on  
January 24, 2023, less than two years prior, which were paid for by the Plan. Therefore, you have exhausted the 
allowable benefit for the service provided in this case. Therefore, we decided that the Plan does not have to pay 
for the intraoral-periapical first radiographic image (D0220) provided on May 2, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on March 30, 2023, to April 03, 
2023. 
 
You asked the Plan to pay for physical therapy. You say that you are appealing the claim payment denial. 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 physical therapy 
provided on March 30, 2023, to April 03, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the porcelain/ceramic retainer crowns (D6740 x 2) and the 
porcelain/ceramic pontic (D6245) provided on January 17, 2023. 
 
You asked the Plan to pay for the dental items. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the dental items 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 dental items from an out-of-network provider. Though the Plan offers a 
dental benefit in excess of Medicare coverage, dental items/services provided 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 the porcelain/ceramic retainer crowns (D6740 x 2) 
and the porcelain/ceramic pontic (D6245) provided on January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an injection provided at an outpatient 
hospital facility provided on April 21, 2022. 
 
You asked the Plan to waive the copayment for an injection provided at an outpatient hospital facility. You say 
that you already paid this same amount and you are being charged again for the same procedure. 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 surgery. 
 
You have been asked to pay a $350 copayment for an injection provided at an outpatient hospital facility. This 
item/service falls within the outpatient surgery 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 previous $350 copayment applied was for the same procedure 
provided on a separate date of service. Therefore, we decided that the Plan does not have to waive the 
copayment for an injection provided at an outpatient hospital facility provided on April 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extraction, of an erupted tooth requiring removal of bone 
and/or sectioning of tooth, for tooth number 14 (D7210) provided on March 13, 2023. 
 
You asked the Plan to pay for this dental service. You say that you are requesting a reconsideration of the 
Plans denial for payment. The Plan denied your request. The Plan says your benefit for the service provided 
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 service provided was exhausted on date of service March 13, 2023.  
  
 
 
Specifically, the Plans contract states that one dental extraction is covered per year. On this day, two dental 
extractions were performed for teeth number 2 and 14. The Plan issued payment on May 4, 2023 for the dental 
extraction provided for tooth number 2. Therefore, you have exhausted the allowable benefit for the dental 
service provided in this case. Therefore, we decided that the Plan does not have to pay for the extraction, of an 
erupted tooth requiring removal of bone and/or sectioning of tooth, for tooth number 14 (D7210) provided on 
March 13, 2023.