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

 
We decided that the Plan does not have to pre-approve the additional routine transportation trips. 
 
You asked the Plan to pre-approve the additional routine transportation trips. You say that you are requesting 
28 additional trips. The Plan denied your request. The Plan says the benefit has been exhausted. 
 
 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 48 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 the additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the retainer crown - full cast noble metal (D6792) provided 
on April 25, 2023. 
 
You asked the Plan to pay for the retainer crown. You say that if you had known you would have to pay for this 
service, you wouldnt have said yes to it as you are retired and dont work. The Plan denied your request. The 
Plan says your benefit for the requested 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 service was exhausted on date of service April 25, 2023 as you already 
received the allowed frequency of 1 (D6752) on the appealed claim. Therefore, we decided that the Plan does 
not have to pay for the retainer crown - full cast noble metal (D6792) provided on April 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous tissue 
regeneration, per site (D4265), the unspecified oral surgery procedure, by report (D7999), and the fixed partial 
denture sectioning (D9120) provided on May 22, 2023. 
 
You asked the Plan to pay for these items/services. You say that you are requesting a reconsideration of the 
Plan's denial for payment. The Plan denied your request. The Plan says the dental items/services provided 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 items/services provided are not 
among those covered under this benefit.   
 
 
Therefore, we decided that the Plan does not have to pay for the biologic materials to aid in soft and osseous 
tissue regeneration, per site (D4265), the unspecified oral surgery procedure, by report (D7999), and the fixed 
partial denture sectioning (D9120) provided on May 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the panoramic radiographic images (D0330 x 2) provided on 
July 24, 2023 and August 17, 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 you have exhausted the allowable benefit for 
the services provided in this case.  
 
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 dental code at issue in this case is 
not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
panoramic radiographic images (D0330 x 2) provided on July 24, 2023 and August 17, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on July 17, 2023. 
 
You asked the Plan to pay for the lab services. You say that the claim should be paid. The Plan denied your 
request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on July 17, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an in-network diagnostic colonoscopy 
provided on June 12th, 2023. 
 
You asked the Plan to waive the deductible for a colonoscopy. You say that this should be covered in full, you 
should not need to pay as this is a screening colonoscopy. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. As there was a biopsy done, that causes this colonoscopy to be a diagnostic 
procedure. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is an $800 deductible which applies to colorectal cancer screening. You 
have been asked to pay $549.53 towards this $800 deductible for 2023. 
 
The item or service you asked the Plan to waive the copayment for falls within the colorectal cancer screening 
benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is an 
$800 deductible which applies to colorectal cancer screening.  This cost sharing is a contractual obligation that had not been met at the time a colonoscopy was received on 
June 12, 2023. Therefore, we decided that the Plan does not have to waive the deductible for an in-network 
diagnostic colonoscopy provided on June 12th, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an out-of-network computed tomography 
(CT) stomach scan provided on July 18, 2023. 
 
You asked the Plan to waive the coinsurance for an out-of-network computed tomography (CT) stomach scan. 
You say that you feel you should not owe this coinsurance. 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 outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay 40% coinsurance for an out-of-network computed tomography (CT) stomach scan. 
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. The total you 
owe is $32.74 ($81.85 x 40% = $32.74). Therefore, we decided that the Plan does not have to waive the 
coinsurance for an out-of-network computed tomography (CT) stomach scan provided on July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the CT scan provided on July 18, 2023. 
 
You asked the Plan to waive the copayment for the CT scan. You say that you thought this was part of your 
pelvic exam and covered at no cost to you for cancer screening. 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 $350 
copayment for outpatient diagnostic tests and therapeutic services and supplies. 
 
You have been asked to pay a $350 copayment for the CT scan. 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 the CT scan provided on July 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for the MRI of the spine provided on August 
18, 2023. 
 
You asked the Plan to waive the deductible for the MRI. You say that you were unaware of the 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. Your 
contract with the Plan says that there is a $750 deductible which applies to the MRI. 
 
You have been asked to pay a $712.27 deductible for the MRI. The item or service you asked the Plan to waive 
the deductible for falls within the outpatient diagnostic tests and therapeutic services and supplies benefit 
category. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $750 
deductible which applies to outpatient diagnostic tests and therapeutic services and supplies. This cost sharing 
is a contractual obligation that had not been met at the time the MRI was received on August 18, 2023. 
Therefore, we decided that the Plan does not have to waive the deductible for the MRI of the spine provided on 
August 18, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency room services provided on 
July 18, 2023. 
 
You asked the Plan to waive the copayment for the emergency room services. You say that you want to appeal 
the amount being charged. 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 $125 
copayment for emergency care. 
 
You have been asked to pay a $125 copayment for the emergency room services. This item/service falls within 
the emergency 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 the emergency room 
services provided on July 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing provided on August 23, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you have made every effort to obtain authorization. 
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 the lab testing provided 
on August 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a denture reline (D5999).  
 
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's 
denial. The Plan denied your request. The Plan says the requested service is not a covered benefit 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 requested service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a denture 
reline (D5999).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services to be provided by an out-of-
network (OON) provider.  
 
You asked the Plan to pre-approve acupuncture services. You say that you need to see an out of network 
provider because there are no in network providers within a reasonable distance. The Plan denied your request. 
The Plan says that acupuncture services are available in network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is necessary. The Plan denied your request. 
The Plan says IRF care is not reasonable and necessary.  
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
medical records support a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. 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. Medically 
necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup, including any pins when required 
(D2950). 
 
You asked the Plan to pre-approve the dental service. You say that since the crown was approved, the core 
build up should be approved as well and the provider can submit clinical documents to support the medical 
necessity. The Plan denied your request. The Plan says your benefit for the requested 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 service was exhausted on date of service September 8, 2020.  Therefore, we decided that the Plan does not have to pre-approve the core buildup, including any pins when 
required (D2950).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a medical eye examination provided on 
August 09, 2023. 
 
You asked the Plan to waive the copayment for a medical eye examination. You say that you did not request a 
cataract check up. 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 $25 
copayment for all other Medicare-covered eye examination. 
 
You have been asked to pay a $25 copayment for a medical eye examination. This item/service falls within the 
all other Medicare-covered eye examination 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 medical eye examination provided on August 09, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that an IRF admission is medically necessary. The Plan 
denied your request. The Plan says the IRF services requested do not meet the requirements for approval.  
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for multiple therapies, including physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. There is not a reasonable expectation that this enrollee 
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an 
IRF. Medically necessary care can be provided in a different level of care.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for consultation (D9310) and biopsy of oral tissue (D7286) 
provided on December 1, 2022. 
 
You asked the Plan to pay for consultation and biopsy of oral tissue. 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 
consultation (D9310) and biopsy of oral tissue (D7286) provided on December 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the injections on July 5, 2023, to August 
3, 2023.  
 
You asked the Plan to waive the coinsurance for the injections. You say that you want to know why the amount 
are different from the August 30, 2023, date of service. 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% 
coinsurance for all other drugs covered under Medicare Part B. The provider billed in the amount of 
$22,948.80 and the allowed amount is $6,631.88. For the service it's $6,631.88 x 20% = $1,326.38. There were 
two dates of service.  For both dates it's $1,326.38 x 2 = $2,652.76. A payment was made in the amount of $60 
($2,652.76 - $60 = $2,592.76). Therefore, results in the total cost sharing amount of $2,592.76. You have been asked to pay a $2,592.76 cost share for the injections. 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. Therefore, we decided that the Plan does not have to waive the coinsurance for 
the injections on July 5, 2023, to August 3, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional wheelchair van services. 
 
You asked the Plan to pre-approve the wheelchair van services. You say that you were informed that you could 
request additional trips. The Plan denied your request. The Plan says the routine transportation benefit has been 
exhausted. 
 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 non-emergency ground transportation 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 wheelchair van services.