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

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on December 12, 2022. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fell 
and the pizza shop owner called the ambulance. The Plan denied your request. The Plan says these services are 
not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on December 12, 2022. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on December 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a complete upper denture (D5110) and a complete 
lower denture (D5120) provided by an out-of-network provider on January 26, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told that you would be covered 
for $2,500 worth of dental services and now the Plan is only paying a certain amount. 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, it was advised that you were told that if 
services were to be done by an out-of-network the provider could bill for the difference. 
 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 each denture was $1,295 with an allowed amount of $714 leaving a difference of 
$581 ($1,295 billed - $714 allowed). The total difference for both dentures was $1,162 ($581 difference x 2 
dentures). 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 complete upper denture (D5110) and a 
complete lower denture (D5120) provided by an out-of-network provider on January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve localized delivery of antimicrobial agents tooth #'s 14 
and 15 (D4381). 
 
You asked the Plan to pre-approve the localized delivery of antimicrobial agents. You say that since this is for 
an infection you think it would be covered under medical not dental. You also say that you know someone that 
passed away from not getting the medication for this infection. The Plan denied your request. The Plan says 
this service is not covered under your dental 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 
localized delivery of antimicrobial agents tooth #'s 14 and 15 (D4381).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device provided on February 8, 
2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not 
have to pay for the pneumatic compression device provided on February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on February 2, 2023. 
 
You asked the Plan to pay for 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 June 7, 2021. Therefore, we decided that the Plan does not have to pay for comprehensive oral evaluation (D0150) and intraoral - 
complete series of radiographic images (D0210) provided on February 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontic - porcelain/ceramic tooth #'s 7 and 10 
(D6245). 
 
You asked the Plan to pre-approve the pontics - porcelain/ceramic. You say that you don't have the money to 
cover the services, and for your health you want to emphasize that the denture is not good for you. You also say 
that you get headaches, migraines, nauseated and your doctor recommended the bridge. The Plan denied your 
request. The Plan says the pontic - porcelain/ceramic is not covered under your dental 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 pontic - porcelain/ceramic is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a 
pontic - porcelain/ceramic tooth #'s 7 and 10 (D6245).
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Renflexis. 
 You asked the Plan to pre-approve Renflexis. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Renflexis. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the enrollee has not tried and failed the 
required drugs. There is no documentation provided indicating that the plan's required drug would likely be less 
effective and/or likely have adverse effects for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Renflexis have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Renflexis.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation - problem focused (D0140) and fixed 
partial denture sectioning (D9120) provided on March 7, 2023. 
 
You asked the Plan to pay for the dental services. You say that you believe these procedures should be covered 
under your plan to provide reasonable dental health. 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 D0140 but is limited to one procedure per plan year. This benefit includes only those items and 
services specifically listed in your Plan contract. Fixed partial denture sectioning (D9120) is not covered under 
the Plans dental benefits. 
 
We looked at the file, the Plans rules, and Medicares rules. You previously received covered limited oral 
evaluation - problem focused (D0140) on February 20, 2023. Therefore, this benefit was exhausted as of March 
7, 2023. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested fixed partial 
denture sectioning (D9120) is not among those covered under this benefit. Therefore, we decided that the Plan 
does not have to pay for limited oral evaluation - problem focused (D0140) and fixed partial denture sectioning 
(D9120) provided on March 7, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for limited oral evaluation (D0140), and cone beam CT capture 
& interpretation (D0367) provided on March 21, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your benefit for the limited oral evaluation has already been exhausted and a cone beam 
CT 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, certain limitations apply. The record 
shows your benefit for the limited oral evaluation was exhausted on date of service January 3, 2023, and January 26, 2023. Therefore, we decided that the Plan does not have to pay for limited oral evaluation (D0140), 
and cone beam CT capture & interpretation (D0367) provided on March 21, 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 need IRF services because you are bed bound 
and cannot move. The Plan denied your request. The Plan says the IRF services requested do not meet the 
requirements 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 that you do 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 you 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health service provided on November 27, 2022, to 
March 23, 2023. 
 
You asked the Plan to pay for home health service. You say that you were told several times that your Plan 
covered home care. The Plan denied your request. The Plan says Medicare does not cover custodial level of 
care. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of home health service have not been met. Specifically, we find that the services at issue in this case 
are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for home health 
service provided on November 27, 2022, to March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of torus mandibularis (D7473) provided on January 
10, 2023. 
 
You asked the Plan to pay for the removal of torus mandibularis. You say that you are requesting that the 
removal of the mandibular torus be covered. The Plan denied your request. The Plan says this 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, removal of torus mandibularis is not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for removal 
of torus mandibularis (D7473) provided on January 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have  to waive the coinsurance for restorative dental services provided on 
March 28, 2023. 
 
You asked the Plan  to waive the coinsurance for restorative dental services. You say that this should be 
covered. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for comprehensive dental services: restorative services, endodontics, periodontics, and extractions.  
 
You have been asked to pay 20% coinsurance for restorative dental services. This item/service 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 coinsurance for restorative dental services 
provided on March 28, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on March 3, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. 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 September 29, 2021. 
Therefore, we decided that the Plan does not have to pay for an intraoral x-ray (D0210) provided on March 3, 
2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for tissue graft procedures (D4278, D4277) provided on 
September 7, 2022. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the charges and was told the Plan would pay 25%. The Plan denied your request. The Plan says the 
services denied correctly as they do not fall within 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 pay for tissue 
graft procedures (D4278, D4277) provided on September 7, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a CT scan of the chest provided on February 1, 2023, by an 
OON provider.  
 
You asked the Plan to pay for the CT scan. You say that you are requesting reconsideration of the denied 
authorization. The Plan denied your request. The Plan says this service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for a CT scan of the chest provided on February 1, 
2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chiropractic service provided on February 3, 2023. 
 
You asked the Plan to pay for chiropractic service. You say that it is medically necessary. The Plan denied your 
request. The Plan says the Plan has limited chiropractic benefits and these services are excluded. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for chiropractic service provided on February 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) for tooth #31 provided by an out-of-
network provider on February 27, 2023. 
 
You asked the Plan to pay more for the dental service. You say that you have gone to the same dentist for years 
and you understood that they were out-of-network, but the Plan only covered less than half the bill. 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. 
 
  The total amount billed for the crown was $1,306 and the total allowed amount was $613 leaving a difference 
of $693 ($1,306 billed - $613 allowed). 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 crown 
(D2740) for tooth #31 provided by an out-of-network provider on February 27, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Grafix PRIME, GrafixPL PRIME, Stravix and 
StravixPL, per sq cm (Q4133) and Oasis wound matrix, per sq cm (Q4102). 
 
You asked the Plan to pre-approve skin substitutes. You say that the services are necessary. The Plan denied 
your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not 
been met. 
 
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 skin substitutes. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the review has determined that records do not show that the enrollee's wound has failed to heal 
by 50% after 4 weeks. There is no evidence that she has been offloading the ulcer or that her blood sugar control has been assessed and is adequate. The requested items/services at issue in this case are 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 skin substitutes have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Grafix PRIME, GrafixPL PRIME, Stravix and StravixPL, per sq cm (Q4133) and Oasis 
wound matrix, per sq cm (Q4102).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unspecified removable prosthodontic procedure, by 
report (D5899) provided on April 17, 2023. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this 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 service provided is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the unspecified 
removable prosthodontic procedure, by report (D5899) provided on April 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intravenous moderate (D9239 and D9243) provided on 
March 20, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are upset with the way the services were 
handled and how much you had to pay out of pocket. The Plan denied your request. The Plan says the denial of 
payment for these services is correct, because the intravenous moderate 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 items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
intravenous moderate (D9239 and D9243) provided on March 20, 2023.