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

 
We decided that the Plan has to pre-approve a crown (D2740) for tooth #28, #29, #30, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that the requested crowns are medically 
necessary. The Plan denied your request. The Plan says that the denial of authorization for the crowns is 
correct, because services to restore damage from attrition, abrasion, erosion, or abfraction are not covered. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the dental 
services 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 the dental services. Our reviewer says 
that the crowns are medically necessary. Our physician reviewer found that the x-ray submitted shows 
recurrent decay in tooth #28 and the photos included support the need for a crown as the decay is large, and the 
existing filling is large. Once the existing filling and decay is removed, the tooth will require a crown due to the 
tooth missing more than 50% of its natural tooth structure. Tooth #31 shows recurrent decay, leaky margins 
around the existing filling, and minimal tooth structure around the existing filling, and a full coverage crown is 
medically necessary. From the photo, tooth #29 has an existing large amalgam, recurrent decay, and minimal 
tooth structure around the filling that makes the natural tooth structure prone to fracture. A full coverage crown 
is medically necessary for tooth #29. The photo for tooth #30 shows a large composite filling that is failing. 
There is leakage around the margins of the filling, and after the filling is removed, more than 50% of the 
natural structure is missing, and will require a full coverage crown. 
 
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 the dental services have been met. Therefore, we decided that the Plan has to 
pre-approve a crown (D2740) for tooth #28, #29, #30, and #31.  
  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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office or outpatient visit provided on November 21, 2022. 
 
You asked the Plan to pay for office or outpatient visit. You say that the services were medically necessary. 
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 office or outpatient visit 
provided on November 21, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia. 
 
You asked the Plan to pre-approve Prolia. You say that the requested Prolia is medically necessary. The Plan 
denied your request. The Plan says they confirmed that the requested Prolia will be dispensed by a pharmacy 
and brought to the provider's office for administration. 
 
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, 
drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. 
 
In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be 
brought to the office for administration. Since the medication does not represent an expense to the physician 
and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that 
the Plan does not have to pre-approve Prolia.  
 
Benefits for Prolia may be available under Medicare Part D. Contact the Plan that administers Part D benefits 
for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the requested Euflexxa is medically necessary. The 
Plan denied your request. The Plan says that the request for Euflexxa is not supported. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, it is the plans responsibility to show that its decision to deny 
coverage is correct. Records from a plan provider are considered to be within the control of the plan. In cases 
where the plan has not supplied records from a plan provider that are critical to its decision, we may properly 
find that the denial is not medically appropriate or justifiable. Enrollees should not be penalized for a plans 
failure to obtain records that are within the plans control. The plan did not provide sufficient medical records 
in order to determine if the enrollee meets Medicare criteria for Euflexxa. Therefore, we decided that the Plan 
has to pre-approve Euflexxa.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the nerve destruction procedure provided 
on June 22, 2023. 
 
You asked the Plan to waive the copayment for the nerve destruction procedure. You say that you only had a 
$35 copayment in the past. 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 $275 
copayment for in-network outpatient surgery provided at an ambulatory surgical center. 
 
You have been asked to pay a $275 copayment for the nerve destruction procedure. This item/service falls within the in-network outpatient surgery provided at an ambulatory surgical center 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 nerve destruction procedure provided on June 22, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a routine ophthalmological examination including 
refraction (S0621) provided on May 30, 2023. 
 
You asked the Plan to reimburse for a routine ophthalmological examination including refraction (S0621). You 
say that your previous optical provider now uses a different Plan and do not have an optometrist on site. You 
also say that you wanted to see a doctor, so you went to a different vision provider. The Plan denied your 
request. The Plan says your mandatory supplemental vision Plan covers in and out-of-network benefits. The 
Plan also says that you went to an out-of-network provider. The Plan also says that according to your EOC, you 
are responsible for any amount over $40 for eye examinations that includes refraction for out-of-network 
services. 
 
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 these services when you obtain services through an in-network vision provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that there is a $400 allowance for a routine eye 
examination (includes infraction). The Plan rules also say that you pay any amount over $40 for out-of-network 
providers. Based on this information, we decided that the Plan's rules for coverage of a routine 
ophthalmological examination including refraction (S0621) have not been met. Therefore, we decided that the 
Plan does not have to reimburse for a routine ophthalmological examination including refraction (S0621) 
provided on May 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 01, 2023. 
 
You asked the Plan to pay for the office visit. You say that you are requesting 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 the office visit provided 
on March 01, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve surgical extractions, bridge, and core buildup services 
for teeth #6 to #11 and #7 and #10 (D7210, D6245, D2950). 
 
You asked the Plan to pre-approve the dental services. You say that the services should be covered as the 
enrollee disagrees with the denial. The Plan denied your request. The Plan says the services denied correctly as 
the enrollee does not meet the clinical requirements to be approved. 
 
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 the dental 
services 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 the dental services. Our physician 
reviewer found that the medical records provided do not support the requested services. 
 
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 the dental services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve surgical extractions, bridge, and core buildup services for teeth #6 to #11 and #7 and 
#10 (D7210, D6245, D2950).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for medication assisted treatment, methadone and alcohol and/or drug 
screening provided on May 31, 2023. 
 
You asked the Plan to pay for medication assisted treatment, methadone and alcohol and/or drug screening. 
You say that you are an approved Medicare facility and been certified since 2004. The Plan denied your 
request. The Plan says that for payment to be made on OTP claim(s), the provider must be an Opioid Treatment 
Program (OTP) that is SAMHSA certified, CMS enrolled, and billed correctly per CMS guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan rationale incorrectly states that this claim was submitted by a physician 
rather than the OTP facility. The claim shows that the billing provider is the OTP facility. This was submitted 
on a professional claim which is allowed according to the rules. As such, we find that the Plan has not 
substantiated this denial of payment. Therefore, we decided that the Plan has to pay for medication assisted 
treatment, methadone and alcohol and/or drug screening provided on May 31, 2023.  
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a temporary bladder catheter provided on 
May 25, 2023. 
 
You asked the Plan to waive the copayment for a temporary bladder catheter. You say that you say that you 
have not received a copayment for years for this service but now your starting to receive copayments. 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 $45 
copayment for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay a $45 copayment for a temporary bladder catheter. This item/service falls within 
the physician/practitioner services, including doctors office visits 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 temporary bladder catheter provided on May 25, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the custom fabricated abutment  includes placement 
(D6057), and abutment supported porcelain/ceramic crown (D6058) provided on June 15, 2023. 
 
You asked the Plan to pay for the dental services. You say that you were advised that this service would be 
covered and you feel you received incorrect information. The Plan denied your request. The Plan says implant 
services are not a covered benefit under your plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 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 the 
custom fabricated abutment  includes placement (D6057), and abutment supported porcelain/ceramic crown 
(D6058) provided on June 15, 2023.  
 
Your complaint about being misled about the implant services 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a specialist office visit (99214) and a scanning computerized 
ophthalmic diagnostic imaging (92134) provided on March 07, 2023. 
 
You asked the Plan to pay for a specialist office visit (99214) and a scanning computerized ophthalmic 
diagnostic imaging (92134). You say that the provider is credentialed with your office and does not require 
prior 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 a specialist office visit 
(99214) and a scanning computerized ophthalmic diagnostic imaging (92134) provided on March 07, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 10 additional occupational therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that the additional occupational therapy visits 
are medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee has met all 
therapeutic goals and there are no further needs requiring a skilled therapist. The Plan says therapy can proceed safely and effectively through a home exercise program, self-management program, restorative nursing 
program or caregiver assisted program. 
 
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 is independent with lower body dressing and can propel a 
manual wheelchair 200 feet. The enrollee was discharged from occupational therapy because their goals were 
met according to the long-term care facility notes. The enrollee's progress has plateaued, and maintenance of 
function 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 occupational therapy visits.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Stelara. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. 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 pre-approve Stelara.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the emergency department visit, and the 
office visit provided by an in-network provider on April 2, 2023, the medical eye exam provided by an in-
network provider on April 3, 2023, and the office visits provided by an in-network provider on April 4, 2023, 
and April 7, 2023.   
 
You asked the Plan to waive the copayment for the emergency department visit, the eye exam, and the office 
visits. You say that you do not agree with the cost sharing. 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 $90 
copayment for each in and out-of-network emergency room visit, a $30 copayment for each in-network 
Medicare-covered specialist visit, a $40 copayment for in and out-of-network Medicare-covered urgently 
needed services, and a $30 copayment for in-network eye exams to diagnose and treat diseases and conditions 
of the eye.      
 
You have been asked to pay a $31.67 copayment for the emergency department visit because the Plan is only 
holding you responsible for this amount which is less than the $90 copayment. This item/service falls within 
the emergency care benefit category. You have been asked to pay a $37.89 copayment for the office visit on 
April 2, 2023, because the Plan is only holding you responsible for this amount which is less than the $40 
copayment. This item/service falls within the urgently needed services benefit category. You have been asked 
to pay a $30 copayment for the eye exam. This item/service falls within the vision care benefit category. You 
have also been asked to pay a $27 copayment for each office visit provided on April 4, 2023, and April 7, 2023. 
These items/services fall within the physician/practitioner services, including doctors office visits 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 department visit, and the office 
visit provided by an in-network provider on April 2, 2023, the medical eye exam provided by an in-network 
provider on April 3, 2023, and the office visits provided by an in-network provider on April 4, 2023, and April 
7, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for duplex scan of extremity veins provided on March 7, 2023. 
 
You asked the Plan to pay for duplex scan of extremity veins. You say that the services were medically 
necessary. The Plan denied your request. The Plan says with the information we have, we cannot determine 
how the member came to the servicing provider, whether the billed services were actually performed, or that 
the services were medically necessary.  
 
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 duplex scan of extremity veins have 
been met. Therefore, we decided that the Plan does not have to pay for duplex scan of extremity veins provided 
on March 7, 2023.