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

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that the additional transportation 
is necessary. The Plan denied your request. The Plan says the benefit has been exhausted. Therefore, coverage 
criteria have not been met. 
 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 12 one-way trips per year.  
 
We looked at your request, the records in the case file, and the rules. 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 additional routine transportation.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for CT scans provided on October 6, 2022, 
and October 10, 2022, by an OON provider. 
 
You asked the Plan to waive the coinsurance for CT scans. You say that you feel like you do not owe anything. 
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 10% 
coinsurance for outpatient diagnostic radiology services, including CT scans.  
 
 
  You have been asked to pay $479.81 coinsurance for CT scans. This total includes $66.43 for the CT scan 
provided on October 6, 2022 ($664.20 allowed x 10% = $66.43) and $413.38 for the CT scan provided on 
October 10, 2022 ($4,133.75 allowed x 10% = $413.38). This item/service falls within the outpatient diagnostic 
tests benefit category. This means that you have been asked to pay the correct amount based on your contract 
with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the coinsurance for CT scans provided on October 
6, 2022, and October 10, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF is not medically 
necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee has stabilized medically and has been receiving skilled rehabilitation 
services in an inpatient rehabilitation facility (IRF). The enrollee has tolerated inpatient rehabilitation services 
and continues to improve with daily skilled nursing and/or skilled therapy services. The enrollee could benefit 
from continued services at the current level of care. The enrollee has made slow progress with therapy, there is 
no indication that transfer to a skilled nursing facility is required. The enrollee can continue to receive skilled 
rehabilitation services at the current IRF or be stepped down to a lower level of care when appropriate. There 
are no services offered at a SNF that are not offered at an inpatient rehabilitation 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a magnetic resonance imaging (MRI) 
provided on January 19, 2023. 
 
You asked the Plan to waive the copayment for a magnetic resonance imaging (MRI). You say that the 
provider waited a year to inform you that you owe a cost-share. 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 $20 
copayment for outpatient diagnostic tests.  
You have been asked to pay a $20 copayment for a magnetic resonance imaging (MRI). This item/service falls 
within the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for a 
magnetic resonance imaging (MRI) provided on January 19, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on January 20, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that there is no authorization for the services 
provided. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on January 20, 2023.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a SNF stay provided from March 1, 2023, 
to March 21, 2023. 
 
You asked the Plan to waive the copayment for a SNF stay. You say that you did not give the facility 
permission to keep the enrollee beyond the 20 days and the additional days were unnecessary. 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). The enrollees contract with the Plan clearly says that enrollees 
must pay $0 copayment for days 1 to 20, a $160 copayment per day for days 21 to 44, and then $0 copayment 
for days 45 to 100 for SNF care.  
 The enrollee has been asked to pay $800 copayment for a SNF stay ($160 per day x 5 days = $800). This 
item/service falls within the SNF care benefit category. This means that the enrollee has been asked to pay the 
correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee 
agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the 
copayment for a SNF stay provided from March 1, 2023, to March 21, 2023.  
 
Your complaint about the facility keeping the enrollee additional days without your consent is not a valid 
appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. 
Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for the intraoral radiographic images (D0220) and to pay 
for the crown (D2740) and the core buildup (D2950) for tooth #30 provided by an out-of-network provider on 
December 13, 2022, and December 14, 2022. 
 
You asked the Plan to pay more for the dental services. You say that your crown was cracked, and you could 
not wait 5 years for a replacement tooth. 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, your benefit for the crown and the core buildup 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. For the intraoral radiographic image that was provided on December 13, 2022, the total amount billed was $28 
and the total allowed amount was $12 leaving a difference of $16 ($28 billed - $12 allowed). For the intraoral 
radiographic image that was provided on December 14, 2022, the total amount billed was $28 and the total 
allowed amount was $12 leaving a difference of $16 ($28 billed - $12 allowed). The total difference amount for 
both services was $32 ($16 difference + $16 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. The 
record shows your benefit for the crown (D2950) and the core buildup (D2950) for tooth #30 was exhausted on 
the date of service of February 17, 2020. Therefore, we decided that the Plan does not have to pay more for the 
intraoral radiographic images (D0220) and to pay for the crown (D2740) and the core buildup (D2950) for 
tooth #30 provided by an out-of-network provider on December 13, 2022, and December 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility provided on March 16, 2023. 
 
You asked the Plan to pay for skilled nursing facility. You say that you would like a reconsideration of the 
denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not 
covered. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for skilled nursing facility 
provided on March 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a custom fabricated abutment (D6057) and abutment 
supported crown (D6058). 
 
You asked the Plan to pre-approve the dental services. You say that you are appealing the denial. The Plan 
denied your request. The Plan says these services are 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 pre-approve a 
custom fabricated abutment (D6057) and abutment supported crown (D6058).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the extractions, of an erupted tooth requiring removal of 
bone and/or sectioning of tooth (D7210) provided on April 11, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under the 
supplemental dental policy.  
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the extractions, 
of an erupted tooth requiring removal of bone and/or sectioning of tooth (D7210) provided on April 11, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the osteogenesis stimulator (E0748), provided on July 22, 
2022. 
 
You asked the Plan to pay for the osteogenesis stimulator. You say that the item should be covered. The Plan 
denied your request. The Plan says  the provider did not submit the medical records for the correct patient. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the osteogenesis stimulator have been 
met. Relevant medical records were not submitted. Therefore, we decided that the Plan does not have to pay for 
the osteogenesis stimulator (E0748), provided on July 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device (A9279) provided on March 18, 2023. 
 
You asked the Plan to pay for the monitoring device. You say that the item should be covered. The Plan denied 
your request. The Plan says this item is statutorily non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that a monitoring device (A9279) is statutorily non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the monitoring device have not been met. Therefore, we decided that the Plan does not have to pay 
for the monitoring device (A9279) provided on March 18, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the monitoring device (A9279) provided on March 14, 2023. 
 
You asked the Plan to pay for the monitoring device . You say that the item should be covered. The Plan denied 
your request. The Plan says this is not a covered item. 
 
The Plan must follow Medicare rules. Medicare rules say that a monitoring device (A9279) is statutorily non-
covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the monitoring device  have not been met. Therefore, we decided that the Plan does not have to pay 
for the monitoring device (A9279) provided on March 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an upper partial denture (D5213), and a lower partial 
denture (D5214). 
 
You asked the Plan to pre-approve the dental services. You say that you want the Plan to cover these services. 
The Plan denied your request. The Plan says dental services from an out-of-network provider 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. 
 
   
You are requesting 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 pre-approve an upper 
partial denture (D5213), and a lower partial denture (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve pontic for teeth 19 and 30 (D6241) and retainer crown 
for teeth 18, 20, 29 and 31 (D6751). 
 
You asked the Plan to pre-approve pontic and retainer crown. You say that this is medically necessary. The 
Plan denied your request. The Plan says to approve a bridge, you must be missing only one upper front tooth or 
only two lower front teeth. The two lower front teeth must be next to each other. You also cannot be missing 
any of your back teeth. Our dentist looked at the x-rays your dentist sent us and said you are missing other 
teeth. Additionally, with bilateral missing posterior teeth, as well as the poor periodontal condition (by the 
provider's own progress notes) of the proposed abutment teeth, the long-term prognosis of fixed bridgework is 
severely compromised. Removable partial denture may be considered. 
 
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 Plan covers pontic and retainer crown when the services are medically necessary and reasonable.  
 
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 pontic and retainer crown. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found bridges should not be placed on 
teeth that have a poor periodontal prognosis. The bone is what holds the teeth in place, and when the 
foundation around the teeth is compromised, bridges are not recommended as these teeth may need to be 
extracted in the future. It has also been noted per the clinical notes that tooth number 31 has a poor crown to 
root ratio, furcation involvement, and deemed to have poor prognosis by the clinician who saw the enrollee on 
6/26/2023. Alternative treatment options should be considered for the enrollee. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of pontic and retainer crown have not been met. Therefore, we decided that the 
Plan does not have to pre-approve pontic for teeth 19 and 30 (D6241) and retainer crown for teeth 18, 20, 29 
and 31 (D6751).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane injections. 
 You asked the Plan to pre-approve Durolane injections. 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. 
 
The Plan follows Medicare rules. Medicare rules say that viscosupplementation therapy for the knee via intra-
articular injections of hyaluronic preparations will be considered medically reasonable and necessary when 
certain conditions are met. 
 
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 Durolane injections. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found there is no documentation of 
physical therapy, home exercise program (HEP) or other non-drug therapy. Therefore, the request does not 
meet the LCD criteria, is deemed not medically reasonable and 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 Durolane injections have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Durolane injections.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation mileage. 
 
You asked the Plan to pre-approve additional routine transportation mileage. You say that the additional 
transportation mileage is necessary. The Plan denied your request. The Plan says the benefit has been 
exhausted. Therefore, coverage criteria have not been met. 
 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 unlimited one-way trips that do not exceed 30 miles. 
 
We looked at your request, the records in the case file, and the rules. 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 additional routine transportation mileage.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drugs, Self-Administered. 
 
You asked the Plan to pay for the 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 pay for the drugs, Self-Administered.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for piflufolastat, a chemical agent provided on 
April 03, 2023. 
 
You asked the Plan to waive the coinsurance for piflufolastat, a chemical agent. You say that you were not 
aware there would be a cost for the dye the facility used during the procedure. The Plan denied your request. 
The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for outpatient diagnostic tests. 
 
You have been asked to pay 20% coinsurance for piflufolastat, a chemical agent. This item/service falls within 
the outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. The total you owe is $1,248.30, which is 20% of the allowed amount for medical supplies, 
including chemical agents ($6,241.50 allowed x 20% = $1,248.30). Therefore, we decided that the Plan does 
not have to waive the coinsurance for piflufolastat, a chemical agent provided on April 03, 2023.