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

 
We decided that the Plan does not have to pay for an abutment supported retainer (D6068) provided on June 5, 
2023. 
 
You asked the Plan to pay for D6068. You say that you would like the Plan to pay for this. The Plan denied 
your request. The Plan says this is not a covered 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 pay for an 
abutment supported retainer (D6068) provided on June 5, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Repatha SureClick. 
 
You asked the Plan to pre-approve the medication. You say that the enrollee cannot take any other medication. 
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 Repatha SureClick.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional tooth to be added to an existing partial denture 
(D5650) provided on May 18, 2023. 
 
You asked the Plan to pay for D5650. You say that you need this dental work. The Plan denied your request. 
The Plan says the denied dental 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 an 
additional tooth to be added to an existing partial denture (D5650) provided on May 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for an extraction (D7210) for tooth #10 provided by an 
out-of-network provider on May 24, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you do not agree on how the claim was 
processed and you should only be responsible for the 50% of the cost. 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. Also, the proper cost share was applied. 
 
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 total amount billed for the extraction was $525 and the total allowed amount was $176.36 leaving a 
difference of $348.64 ($525 billed - $176.36 allowed amount). The total coinsurance amount was $88.18 
($176.36 allowed x 50% coinsurance). Prior to the date of service, the total amount paid towards the yearly 
deductible was $16.15 leaving a balance of $83.85 ($100 deductible - $16.15 paid towards deductible). 
Therefore, $83.85 was applied to the yearly $100 deductible. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment, along with the annual deductible. 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 an extraction 
(D7210) for tooth #10 provided by an out-of-network provider on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an unspecified removable prosthodontic procedure, by report 
(D5899) provided on April 24, 2023. 
 
You asked the Plan to pay for the unspecified removable prosthodontic procedure, by report. The Plan denied 
your request. The Plan says this service is not a covered benefit under 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 pay for an unspecified 
removable prosthodontic procedure, by report (D5899) provided on April 24, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on May 22, 2023. 
 
You asked the Plan to pay for the implantable, insertable, and wearable cardiac device evaluation. You say that 
the services were medically necessary. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were 
they approved in advance. 
 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 did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for an implantable, insertable, and wearable cardiac device 
evaluation provided on May 22, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's complex care needs and for them to receive intensive therapy services to regain their independence 
for a safe return home. The Plan denied your request. The Plan says the enrollee does not meet the criteria for 
admission to an IRF.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the labial veneer (D2962), pontic (D6245) and retainer 
crowns (D6740 x 2) provided from March 16, 2023, to April 18, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had a dental emergency and needed your 
front teeth replaced. This was a medical issue and should be covered under your medical benefit.  The Plan 
denied your request. The Plan says these services are not covered benefits 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. Additionally, these services are not covered under your medical 
benefit. Therefore, we decided that the Plan does not have to pay for the labial veneer (D2962), pontic (D6245) 
and retainer crowns (D6740 x 2) provided from March 16, 2023, to April 18, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on June 20, 2023. 
 
You asked the Plan to pay for the local anesthesia. You say that you say that you were advised by the provider 
that this service was needed due to it being a very deep filling and the nerve had to be touched. The Plan denied 
your request. The Plan says this service is not covered. 
 
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 pay for the local 
anesthesia in conjunction with operative or surgical procedures (D9215) provided on June 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation treatment delivery and 
management provided on May 17, 2023. 
 
You asked the Plan to waive the coinsurance for radiation treatment delivery and management. You say that 
you were not aware that you had a 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 20% 
coinsurance for therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for radiation treatment delivery and management. This 
item/service falls within the therapeutic radiology 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. The total you owe is $83.38 ($416.88 allowed 
amount x 20% = $83.38 rounded up). Therefore, we decided that the Plan does not have to waive the 
coinsurance for radiation treatment delivery and management provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a panoramic radiographic image (D0330) provided on 
June 26, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you were told the provider was in-network 
and they are charging you $50.00. You also say that you are appealing this charge. 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 panoramic radiographic image (D0330) 
provided on June 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 23, 2023, to May 30, 2023. 
 
You asked the Plan to pay for the dental services. You say that you got this provider from a list that the Plan 
gave you for participating dentists. 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 dental services provided on May 23, 2023, to May 30, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on May 11, 2023. 
 
You asked the Plan to pay for the dental services. You say that you would like some kind of refund. 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 dental services provided on May 11, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that you do not have use of your legs due to torn 
ligaments and are constantly falling. The Plan denied your request. The Plan says the enrollee's condition is 
stable and does not meet the criteria for an IRF admission.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for local anesthesia in conjunction with operative or surgical 
procedures (D9215) provided on July 19, 2023. 
 
You asked the Plan to pay for the local anesthesia. You say that you received Novocain to have some fillings 
done. You also say that you were told you would need to be numbed as the fillings were deep. The Plan denied 
your request. The Plan says service D9215 is not covered under your contract. 
 
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 pay for local anesthesia 
in conjunction with operative or surgical procedures (D9215) provided on July 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that 
were issued on April 19, 2023. 
 
You asked the Plan to pay for the compression stockings. You say that you had cancer and your lymph nodes 
were removed. You also say that this caused your lymphedema and you need the stocking to control the 
swelling of your leg. The Plan denied your request. The Plan says there is no documentation that you have a 
qualifying wound present. The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression 
stockings identified with code A6533 that were issued on April 19, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from an IRF admission. The 
Plan denied your request. The Plan says the IRF services requested do not meet the criteria for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. There is not a reasonable expectation that this enrollee will be able to fully participate in 
and benefit from the intensive rehabilitation therapy program provided in an IRF. Medically necessary care can 
be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the services are medically necessary for the 
enrollee's care needs. The Plan denied your request. The Plan says the enrollee seems more appropriate for 
rehabilitation in a skilled nursing facility.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. Medically necessary care can be provided in a different level of 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department (ED) services provided on April 
29, 2023. 
 
You asked the Plan to pay for the ED services. You say that you sent the additional documents and would like 
the claim reprocessed. The Plan denied your request. The Plan says Medicare payment cannot be made to this 
type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare. 
However, during the COVID-19-PHE, such providers were allowed to enroll as temporary hospitals and could 
be paid for services during this period. 
 
We looked at the file and Medicare rules. We find that the provider at issue has not enrolled as a temporary 
hospital as allowed during the PHE. As such, this provider is not eligible for Medicare payment. Therefore, we 
decided that the Plan does not have to pay for the emergency department (ED) services provided on April 29, 
2023.