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

 
We decided that the Plan does not have to pay for a porcelain/ceramic retainer crown (D6740) and a 
porcelain/ceramic pontic (D6245) provided on June 20, 2023. 
 
You asked the Plan to pay for a porcelain/ceramic retainer crown (D6740) and a porcelain/ceramic pontic 
(D6245). You say that you were told both services would be covered at 50% with this Plan and to add the 
policy. The Plan denied your request. The Plan says these services are not listed codes for coverage under this 
dental Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a 
porcelain/ceramic retainer crown (D6740) and a porcelain/ceramic pontic (D6245) provided on June 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for colorectal screening provided on February 07, 2023. 
 
You asked the Plan to pay for colorectal screening. You say that your facility does not need prior authorization 
for testings. 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 colorectal screening 
provided on February 07, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an onabotulinumtoxina injection provided 
on May 11, 2023. 
 
You asked the Plan to reduce the coinsurance for an onabotulinumtoxina injection. You say that you disagree 
with the increased allowed amount. 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 Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for an onabotulinumtoxina injection. This item/service falls 
within the Medicare Part B prescription drugs 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 amount you owe is $247.40 ($1,237.02 allowed amount x 20% = 
$247.40). Therefore, we decided that the Plan does not have to reduce the coinsurance for an 
onabotulinumtoxina injection provided on May 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), an unspecified 
preventive procedure (D1999), and a retainer crown (D6750) for tooth #6 provided on April 24, 2023. 
 
You asked the Plan to pay for the dental services. You say that you are requested the reimbursement for the 
denied dental services. The Plan denied your request. The Plan says your benefit for the panoramic 
radiographic image and retainer crown has already been exhausted. Also, the unspecified preventive procedure 
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, certain limitations apply. The record 
shows the Plan paid for a panoramic radiographic image (D0330) on March 21, 2022; therefore, your benefit 
for the panoramic radiographic image (D0330) was exhausted on the date of service of March 21, 2022. The 
record also shows the Plan paid for a retainer crown (D6750) for tooth #2, #4, and #5 and a pontic (D6240) for 
tooth #3 on April 24, 2023; therefore, your benefit for the retainer crown (D6750) for tooth #4 was exhausted 
on the date of service of April 24, 2023. The unspecified preventive procedure is not covered under the Plans 
dental benefit. Therefore, we decided that the Plan does not have to pay for a panoramic radiographic image 
(D0330), an unspecified preventive procedure (D1999), and a retainer crown (D6750) for tooth #6 provided on 
April 24, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation treatment delivery provided on 
May 12, 2023. 
 
You asked the Plan to waive the coinsurance for radiation treatment delivery. You say that you do not have the 
money to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for radiation treatment delivery. This item/service falls within 
the therapeutic radiology services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $44.86 ($224.28 allowed amount x 20% = $44.86 rounded 
up). Therefore, we decided that the Plan does not have to waive the coinsurance for radiation treatment delivery 
provided on May 12, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the application of desensitizing medicament (D9910) 
provided on May 1, 2023. 
 
You asked the Plan to pay for the dental services. You say that no one from the dental office called to tell you 
that only one was allowed in the year. 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 April 26, 2023. 
Therefore, we decided that the Plan does not have to pay for the application of desensitizing medicament 
(D9910) provided on May 1, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for canning computerized ophthalmic diagnostic imaging 
(92133) and an office visit (99205) provided on March 10, 2023. 
 
You asked the Plan to pay for canning computerized ophthalmic diagnostic imaging (92133) and an office visit 
(99205). You say that you called the provider and they said they took your insurance. 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 canning computerized 
ophthalmic diagnostic imaging (92133) and an office visit (99205) provided on March 10, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health aide services provided from December 20, 
2022, to March 23, 2023. 
 
You asked the Plan to pay for the home health aide services. You say that you are requesting reimbursement 
for the services that were provided and that they are a covered expense. The Plan denied your request. The Plan 
says the denial of payment was correct, because the enrollee was receiving custodial services such as meal 
prep, bathing, pet care, medication reminders, and companionship. 
 
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 the home health aide services 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 the 
home health aide services provided from December 20, 2022, to March 23, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation treatment delivery provided on 
May 08, 2023. 
 
You asked the Plan to waive the coinsurance for radiation treatment delivery. You say that you do not have the 
money to pay. The Plan denied your request. The Plan says this cost sharing was charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for therapeutic radiology services. 
 
You have been asked to pay 20% coinsurance for radiation treatment delivery. This item/service falls within 
the therapeutic radiology services benefit category. This means that you have been asked to pay the correct 
amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. The total you owe is $44.86 ($224.28 allowed amount x 20% = $44.86 rounded 
up). Therefore, we decided that the Plan does not have to waive the coinsurance for radiation treatment delivery 
provided on May 08, 2023.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pre-approve 10 visits of additional physical therapy.  
 
You asked the Plan to pre-approve the therapy services. You say that 10 additional physical therapy services 
are needed for the enrollee's lumbar region. The Plan denied your request. The Plan says that 10 additional 
physical therapy services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that 10 visits of additional physical therapy are medically necessary. Our physician reviewer found 10 visits of 
additional physical therapy are medically necessary. Our physician reviewer found that the enrollee has had 19 
sessions of physical therapy. She has made gradual progress in terms of improving the strength of her left lower 
extremity and is able to ambulate for longer distances and negotiate stairs without assistance or less assistance. 
However, she continues to have decreased strength, mobility and pain. She would benefit from an additional 10 
visits of physical therapy for continued strengthening and transitioning to a home exercise program. 
 
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 therapy services have been met. Therefore, we decided that the Plan has to 
pre-approve 10 visits of additional physical therapy.   
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft for ridge preservation - per site 
(D7953) provided on August 12, 2022. 
 
You asked the Plan to pay for the bone replacement graft for ridge preservation. You say that this claim was 
denied due to the fact that the provider submitted the claim late. You also say that you feel the reimbursement 
should be approved because you paid for the services up front. The Plan denied your request. The Plan says 
your plan will only cover dental services in a hospital setting or from injury to natural teeth. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for the bone replacement graft for 
ridge preservation - per site (D7953) provided on August 12, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimbursement for hearing aids provided on May 17, 2023. 
 
You asked the Plan to reimbursement for hearing aids. You say that the Plan has sent repayment to you several 
times in the past for hearing aid supplies that you have purchased from this vendor. The Plan denied your 
request. The Plan says hearing aids must be purchased through the Plan hearing to be covered under the  
hearing aid services offered by your Plan. 
 
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 the Plan hearing nationwide network.  
 
 
  We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of hearing aids have not been met. Therefore, we decided that the Plan does not have to 
reimbursement for hearing aids provided on May 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for an in-network nuclear medicine visit 
provided on May 25, 2023. 
 
You asked the Plan to reduce the coinsurance for an in-network nuclear medicine visit. You say that you had a 
CT/PET CT scan done, not this. You should only have a $150 copayment. 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 40% 
coinsurance for Nuclear Medicine Services. 
 
You have been asked to pay 40% coinsurance for an in-network nuclear medicine visit. This item/service falls 
within the Nuclear Medicine Services benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay 
when you enrolled in the Plan. The total you owe is $2,085.68 ($5,214.20 allowed x 40% = $2,085.68). 
Therefore, we decided that the Plan does not have to reduce the coinsurance for an in-network nuclear 
medicine visit provided on May 25, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional physical therapy (PT) visits. 
 
You asked the Plan to pre-approve the therapy services. You say that 10 additional physical therapy visits are 
reasonable and necessary. The Plan denied your request. The Plan says 10 additional physical therapy visits are 
not reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer 
says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the 
enrollee's condition. Our physician reviewer found the enrollee has had 18 sessions of physical therapy. She 
has made gradual progress in terms of improving her strength and ability to ambulate, but her strength has 
essentially remained the same. The enrollee can continue with strengthening exercises with a home exercise 
program. She may require some degree of assistance and supervision for safety given her mobility deficits, 
but this does not require the services of a skilled physical therapist. 
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 therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 10 additional physical therapy (PT) visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a porcelain/ceramic crown (D2740), core buildup (D2950) 
provided on June 6, 2023. 
 
You asked the Plan to pay for a porcelain/ceramic crown (D2740), core buildup (D2950). You say that your 
crown was damaged during root canal treatment. You also say that you believe that these circumstances should 
allow the denied services. The Plan denied your request. The Plan says there is not coverage for core buildup. 
 
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 
porcelain/ceramic crown (D2740), core buildup (D2950) provided on June 6, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788) 
provided on May 24, 2023. 
 
You asked the Plan to pay for presbyopia correcting function of intraocular lens (V2788). You say that you 
should at least receive some payment for the lens cost allowed by Medicare. The Plan denied your request. The 
Plan says presbyopia correcting function of intraocular lens (V2788) is not covered by Medicare or the Plan. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one pair of eyeglasses or contact lenses after each cataract surgery that includes 
insertion of an intraocular lens (additional pairs of eyeglasses or contacts are not covered by Medicare). 
Presbyopia correcting function of intraocular lens (V2788) is excluded from this benefit. 
 
We looked at the file and the Plan's rules. The Plan rules say that presbyopia correcting function of intraocular 
lens (V2788) is excluded from this benefit. Based on this information, we decided that the Plan's rules for 
coverage of presbyopia correcting function of intraocular lens (V2788) have not been met. Therefore, we 
decided that the Plan does not have to pay for presbyopia correcting function of intraocular lens (V2788) 
provided on May 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips (A0100). 
 
You asked the Plan to pre-approve the additional trips. You say that you are a diabetic and  need more 
unlimited rides as you don't have transportation or anyone to take you to your appointments. You also say that 
now you have to wait until next year and have to deal with the pain in your leg for who knows how long.  The Plan denied your request. The Plan says routine transportation benefits beyond the 100 allotted one-way 
trips are not covered under the plan. 
 
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 100 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 because you cannot drive and have upcoming appointments. 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 trips (A0100).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a bone marrow aspirate (20939). 
 
You asked the Plan to pre-approve a bone marrow aspirate. You say that this is medically necessary. The Plan 
denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the setting of 
spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 a bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental. More research is needed when used as bone 
graft material. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a bone marrow aspirate (20939).