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

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) for tooth #29 provided 
on February 10, 2023. 
 
You asked the Plan to pay for the dental service. You say that the bone graft was a surgical procedure and 
should be covered under the oral surgery. The Plan denied your request. The Plan says the denial of payment 
for this service is correct, because the bone replacement graft 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 bone 
replacement graft (D7953) for tooth #29 provided on February 10, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a bone replacement graft for ridge preservation (D7953) 
provided on February 7, 2023. 
 
You asked the Plan to pay for D7953. You say that you did not find out this was not covered until after the 
service was provided. The Plan denied your request. The Plan says the rendered dental service is not a 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 items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a bone 
replacement graft for ridge preservation (D7953) provided on February 7, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network acute inpatient stay provided 
from July 25, 2021, to August 14, 2021. 
 
You asked the Plan to waive the copayment for an in-network acute inpatient stay. You say that this was so 
long ago I do not even remember what I have and have not paid. Also, it took this facility so long to bill you. 
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 $300 
copayment per day, for days 1-5 for inpatient hospital care. You were in the hospital for 5 days, resulting in a 
$1,500 total copayment ($300 x 5 = $1,500). 
 
You have been asked to pay a total copayment of $1,500 for an in-network acute inpatient 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 an in-network acute inpatient stay provided from July 25, 2021, to August 14, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for cone beam CT (D0364) provided on January 17, 2023. 
 
You asked the Plan to pay for cone beam CT. 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 cone 
beam CT (D0364) provided on January 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pin retention - per tooth, in addition to restoration (D2951) 
provided on March 27, 2023. 
 
You asked the Plan to pay for the pin retention - per tooth, in addition to restoration (D2951). You say that you 
wouldn't have your teeth if you didn't have these posts. You also say that crowns and bridges are covered and 
feel they should cover some of this like you cover other procedures. The Plan denied your request. The Plan 
says D2951 is not covered under the Plan's 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 pin 
retention - per tooth, in addition to restoration (D2951) provided on March 27, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the PWC repairs and an integrated drive wheel motor 
replacement. 
 
You asked the Plan to pre-approve the PWC repairs and a replacement motor. You say that the PWC repairs 
are medically necessary. The Plan denied your request. The Plan says that the enrollee's current power 
wheelchair has exceeded its reasonable useful lifetime. 
 
The Plan must follow Medicare rules. Medicare rules say that in the absence of program instructions, carriers 
may determine the RUL, but in no case can it be less than five years. If the item has been in continuous use by 
the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement. 
  
We looked at the file and Medicare rules. The record shows the enrollees current power wheelchair is seven-
year-old and has exceeded its RUL. Therefore, we decided that the Plan does not have to pre-approve the PWC 
repairs and an integrated drive wheel motor replacement.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says the enrollee's medical needs are being met 
at the current facility.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that all medically necessary care is being provided in the current acute care setting.  
There are no services available at the LTACH that the enrollee requires that are not available at the health care 
setting being offered by the Plan. The Plan has approved ongoing care in the current acute care setting.  The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and 
condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for panoramic radiographic image (D0330) provided on 
February 9, 2023. 
 
You asked the Plan to pay for the dental services. You say that the x-ray you received should be covered by 
your insurance. 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 panoramic radiographic image but is limited to one per 36-month period. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows you received a covered panoramic radiographic image (D0330) on January 18, 2022. Therefore, this 
benefit has been exhausted as of February 9, 2023. Therefore, we decided that the Plan does not have to pay for 
panoramic radiographic image (D0330) provided on February 9, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network spine surgery provided on 
May 31, 2022, to December 06, 2022. 
 
You asked the Plan to waive the copayment for an in-network spine surgery. You say that this procedure was 
not successful, and you should not have to pay this money. 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 $245 
copayment for outpatient surgery services. 
 
You have been asked to pay a $245 copayment for an in-network spine surgery. This item/service falls within 
the outpatient surgery services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for 
an in-network spine surgery provided on May 31, 2022, to December 06, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for interim partial denture (including retentive/clasping 
materials, rests, and teeth), maxillary (D5820) provided on November 7, 2022. 
 
You asked the Plan to pay for dental services. You say that you were in a serious accident and needed the 
dental work, so you hope your insurance will cover the billed amount. The Plan denied your request. The Plan 
says this service is not covered 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. Interim partial denture 
(including retentive/ clasping materials, rests, and teeth), maxillary (D5820) is not covered under the Plans 
dental benefits 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D5820 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for interim partial 
denture (including retentive/clasping materials, rests, and teeth), maxillary (D5820) provided on November 7, 
2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for excision of benign lesion up to 1.25 cm (D7410) provided on 
January 25, 2023. 
 
You asked the Plan to pay for dental services. You say that your provider found a papilloma in your mouth and 
had to remove it. The Plan denied your request. The Plan says this service is not covered 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. Excision of benign lesion up 
to 1.25 cm (D7410) is not covered under the Plans dental benefits. 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested D7410 is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for excision of 
benign lesion up to 1.25 cm (D7410) provided on January 25, 2023.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the laboratory services provided on August 16, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan has not provided enough evidence to support the denial of 
payment for the laboratory services based on Medicare criteria. Therefore, we decided that the Plan has to pay 
for the laboratory services provided on August 16, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided on January 18, 2023. 
 
You asked the Plan to pay for self-administered drugs. You say that you are unaware of what is being denied 
and that you have all your medications at home. The Plan denied your request. The Plan says that self-
administered drugs do not fall under Part B coverage. 
 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 
on January 18, 2023.  
 
Benefits for self-administered drugs 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab testing provided on November 11, 
2022. 
 
You asked the Plan to waive the copayment for lab testing. You say that you say that this was about of your 
annual physical. 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 $10 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $10 copayment for lab testing. This item/service falls within the outpatient 
diagnostic tests and therapeutic services and supplies benefit category. This means that you have been asked to 
pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for lab testing provided on November 11, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulatory surgical boot (L3260) provided on  
December 27, 2022. 
 
You asked the Plan to pay for this item. You say that you are requesting a reconsideration of the Plan's denial 
for payment. The Plan denied your request. The Plan says that you do not meet criteria for coverage of the item 
provided in this case. 
 
Medicare rules state that supportive devices for the feet are only covered for patients with diabetic foot disease 
or for patients who wear a leg brace. The Plan follows these same rules.   
 
 
  
 
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although this 
item may be appropriate for you, neither Medicare nor the Plan provides coverage of this item for your 
condition. Additionally, Medicare rules say that with the exception of the situations described, orthopedic 
footwear billed using code L3260 will be denied as non-covered. Therefore, we decided that the Plan does not 
have to pay for the ambulatory surgical boot (L3260) provided on December 27, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for removal of benign odontogenic cyst or tumor - lesion 
diameter up to 1.25 cm (D7450), and guided tissue regeneration - resorbable barrier, per site (D4266) provided 
on February 27, 2023. 
 
You asked the Plan to pay for the dental services represented by codes D7450 and D4266. You say that you 
were informed by the dental representative that the procedure you underwent was a medical procedure that was 
deemed to improve your overall health. You also say that this procedure should have been billed as a medical 
procedure and not a dental procedure  under a different code.  The Plan denied your request. The Plan says 
dental codes D7450 and D4266 are not on the list of covered benefits under this plan under the mandatory or 
optional coverage. 
 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 removal 
of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm (D7450), and guided tissue regeneration - 
resorbable barrier, per site (D4266) provided on February 27, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation (D0120), bitewings 
(D0274), a cleaning (D1110), and an amalgam (D2150) provided by an out-of-network provider on February 2, 
2023, and February 6, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you did not know you had to use in-
network providers. 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. 
 
  For the periodic oral evaluation, the total amount billed was $40 and the total allowed amount was $34.62 
leaving a difference of $5.38. For the bitewings the total amount billed was $75 and the total allowed amount 
was $49.30 leaving a difference of $25.70. For the cleaning the total amount billed was $130 and the total 
allowed amount was $76.53 leaving a difference of $53.47. For the amalgam the total amount billed was $190 
and the total allowed amount was $102.42 leaving a difference of $87.58. The total amount of the differences 
was $172.13 ($5.38 difference + $25.70 difference + $53.47 difference + $87.58 difference). 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 the periodic oral evaluation (D0120), bitewings (D0274), a cleaning 
(D1110), and an amalgam (D2150) provided by an out-of-network provider on February 2, 2023, and February 
6, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says the enrollee does not meet all the requirements 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 that the complexity of the enrollees nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. While the enrollee may have a need for physical 
therapy and/or occupational therapy, there is no documented need for intensive rehabilitation services. 
Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that 
the enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a limited oral evaluation (D0140) and endodontic 
therapy (D3320) provided on February 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were in severe pain and the dental 
services were medically necessary to get done to stop the pain. The Plan denied your request. The Plan says 
your annual dental benefit maximum for the year 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 that the Plan paid $67 for dental services on January 19, 2023. On January 25, 2023, the Plan paid $181 
for dental services. On February 8, 2023, the Plan paid $1,076 for dental services. On February 16, 2023, the 
Plan paid $676 for dental services. For the year of 2023 the Plan paid $2,000 ($67 paid + $181 paid + $1,076 
paid + $676 paid) for dental services; therefore, your annual dental benefit for the year of 2023 was exhausted 
on the date of service of February 16, 2023. Therefore, we decided that the Plan does not have to pay more for 
a limited oral evaluation (D0140) and endodontic therapy (D3320) provided on February 16, 2023.