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

 
We decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a two 
dimensional (2D) oral/facial photographic image (D0350), an intraoral complete series of radiographic images 
(D0210), a panoramic radiographic image (D0330) provided on July 5, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you are appealing with supporting records. 
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. Also, 
though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for  a two dimensional (2D) oral/facial photographic image (D0350) and a panoramic 
radiographic image (D0330) was exhausted on date of service with this date of service, July 5, 2023. Therefore, 
we decided that the Plan does not have to pay more for a comprehensive oral evaluation (D0150), a two 
dimensional (2D) oral/facial photographic image (D0350), an intraoral complete series of radiographic images 
(D0210), a panoramic radiographic image (D0330) provided on July 5, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624). 
 
You asked the Plan to pre-approve genicular nerve radiofrequency ablation. You say that this is medically 
necessary. The Plan denied your request. The Plan says this is not medically necessary. 
 
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 genicular nerve radiofrequency 
ablation. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found this is considered an experimental/investigational 
procedure. It is the subject of ongoing clinical trials. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular nerve radiofrequency ablation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve genicular nerve radiofrequency ablation (64624).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and the panoramic 
radiographic image (D0330) provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you had to change dentist and they needed to do 
the dental services because you were a new patient. The Plan denied your request. The Plan says your benefit 
for the requested items or services 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 the Plan paid for a comprehensive oral evaluation (D0150) and the panoramic radiographic image 
(D0330) on May 26, 2022; therefore, your benefit for the requested items or services was exhausted on the date 
of service of May 26, 2022. Therefore, we decided that the Plan does not have to pay for a comprehensive oral 
evaluation (D0150) and the panoramic radiographic image (D0330) provided on June 15, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a retreatment of root canal therapy (D3348) for tooth #3 
provided on May 17, 2023. 
 
You asked the Plan to pay for the dental service. You say that it was medically necessary for you to get a root 
canal and you were instructed to take care of it right away. The Plan denied your request. The Plan says the 
denial of payment for this service is correct, because the retreatment of root canal therapy is 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 a 
retreatment of root canal therapy (D3348) for tooth #3 provided on May 17, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 6 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you are unable to drive and your 
transportation rides have been used this year for x-rays and doctor visits. You also say that you have been 
referred to a new spinal doctor and this will require additional ride for those visits. The Plan denied your 
request. The Plan says the records show that you have used 23 one-way trips of the 24 allowed.  
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 24 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to pre-approve 
additional routine transportation trips for doctor visits. Based on this information, we decided that you have 
exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the 
Plan does not have to pre-approve 6 additional routine transportation trips (A0120).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics.  
 
You asked the Plan to pre-approve foot orthotics. You say that it is medically necessary for yo to do cardio 
with the orthotics that your doctor prescribed for you. The Plan denied your request. The Plan says this item is 
not a covered benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) 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 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve foot orthotics (L3000). 
 
You asked the Plan to pre-approve foot orthotics. You say that your second and third toe are spreading apart 
and your toes are having extreme pain. You also say that you have  been diagnosed with spondyloarthropathy 
and a bone spur on the top of your foot. The Plan denied your request. The Plan says this item is not a covered 
benefit. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) 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 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics (L3000).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180), and panoramic radiographic image (D0330) provided on June 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that the letter you received from the plan told you 
that you didn't have to pay for anything, the insurance would. The Plan denied your request. The Plan says your 
benefit for the requested services 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 services was exhausted on date of service June 23, 2021. Therefore, we 
decided that the Plan does not have to pay for a comprehensive periodontal evaluation - new or established 
patient (D0180), and panoramic radiographic image (D0330) provided on June 1, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the periodic oral evaluation - established patient 
(D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on June 8, 
2023. 
 
You asked the Plan to pay more for the dental services. You say that the dental office informed you that they 
were in-network. You also say that you went to the appointment and then found out they were no longer in-
network when you received a 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. 
 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 - established 
patient (D0120), bitewings - four radiographic images (D0274), and prophylaxis - adult (D1110) provided on 
June 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the maxillary and mandibular partial dentures - cast 
metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213), and 
(D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you need the partials to help you chew 
your food and digest it properly. You also say that without the partials it is changing the shape of your face. 
The Plan denied your request. The Plan says your benefit for the maxillary and mandibular partial denture 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 maxillary partial denture (D5213) was exhausted on date of service April 23, 2019 
and the mandibular partial denture (D5214) was exhausted on August 5, 2020. Therefore, we decided that the 
Plan does not have to pre-approve the maxillary and mandibular partial dentures - cast metal framework with 
resin denture bases (including retentive/clasping materials, rests and teeth) (D5213), and (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient hospital care. 
 
You asked the Plan to pre-approve acute inpatient hospital care. You say that this is medically necessary. The 
Plan denied your request. The Plan says this is not medically necessary. This can be done at an observational 
level of care. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 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 acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient admission are met in this 
case. Our physician reviewer found the provider is requesting an inpatient level of care admission for a left 
heart catheterization and intravenous (IV) hydration. There is no specific clinical rationale for the request. The 
procedure is an outpatient procedure and there is no documentation provided indicating medical necessity for 
inpatient level of care services. The record did not show that at the time of inpatient admission the admitting 
physician reasonably expects that the enrollee's necessary hospital care (including earlier emergency 
department and/or observation care) will span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pre-approve acute inpatient hospital care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a crown (D2740) and core buildup (D2950) for tooth 
#29 provided by an out-of-network provider on May 17, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you were told you would be reimbursed 
for $2,000 and you were never told about an in-network provider. 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 (D2740) was $1,759 and the total allowed amount was $581 leaving a 
difference of $1,178 ($1,759 billed - $581 allowed). The total amount billed for the core buildup (D2950) was 
$345 and the total allowed amount was $112 leaving a difference of $233 ($345 billed - $112 allowed). The 
total difference amount was $1,411 ($1,178 difference + $233 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 a crown (D2740) and core buildup (D2950) 
for tooth #29 provided by an out-of-network provider on May 17, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's complex medical needs. The Plan denied your request. The Plan says it is not medically necessary 
for the enrollee to move to LTACH for acute level care. 
 
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 the enrollee appears to be improving with current treatment and requires only short-
term additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer to a lower level of care. The enrollee does not require services at the LTACH facility 
that are not already available at the current facility.  
 
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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on May 17, 2022. 
 
You asked the Plan to pay for an office visit. You say that both policies should have paid. The Plan denied your 
request. The Plan says claims must be submitted to primary insurer first. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Medicare is 
secondary payer. As the secondary insurer, the Plan cannot be held responsible for an office visit until the 
primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to 
pay for an office visit provided on May 17, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the overdenture  complete mandibular (D5865), semi-
precision attachment  placement (D6192), and semi-precision abutment  placement (D6191).  
 
You asked the Plan to pre-approve the dental services. The Plan denied your request. The Plan says these 
services are not covered under your benefit plan. The Plan also says that your dentist has stated that the 
overdenture  complete mandibular (D5865) is going over implants. 
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested services are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
overdenture  complete mandibular (D5865), semi-precision attachment  placement (D6192), and semi-
precision abutment  placement (D6191).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a complete lower denture (D5120) and a partial upper 
denture (D5211). 
 
You asked the Plan to pre-approve the dental services. You say that you would like the dentures to be covered. 
The Plan denied your request. The Plan says the denial of authorization for these services is correct, because 
dentures are 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 pre-approve a 
complete lower denture (D5120) and a partial upper denture (D5211).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for binaural hearing aids (V5261), sales tax (S9999), and 
an unlisted special service (99199) provided from April 6, 2023, to April 22, 2023. 
 
You asked the Plan to reimburse for binaural hearing aids (V5261), sales tax (S9999), and an unlisted special 
service (99199). You say that you followed the procedures as closely as possible, but took action as a six week 
wait for hearing aids was unacceptable. The Plan denied your request. The Plan says there is no coverage for 
hearing aids when received from a provider other than the Plan hearing. 
 
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case. The Plan pays for 
hearing aids only when the hearing aids are obtained through a Plan hearing provider.  
 
 
  We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of binaural hearing aids (V5261), sales tax (S9999), and an unlisted special service (99199) have not 
been met. Therefore, we decided that the Plan does not have to reimburse for binaural hearing aids (V5261), 
sales tax (S9999), and an unlisted special service (99199) provided from April 6, 2023, to April 22, 2023.