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

 
We decided that the Plan does not have to pre-approve endosteal implants (D6010) for tooth #29 and #31, and 
second stage implant body (D6011) for tooth #19, #21, #29, and #31. 
 
You asked the Plan to pre-approve the dental services. You say that you would like the Plan to approve these 
dental implants. 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 with the approval of D6010 for tooth #19 and #21. Therefore, we decided that the Plan does not have to pre-approve endosteal implants (D6010) for 
tooth #29 and #31, and second stage implant body (D6011) for tooth #19, #21, #29, and #31.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you would like to request 
reconsideration of the denied claim and that the services requested are medically necessary. The Plan denied 
your request. The Plan says the service is not a covered benefit. 
 The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for dental services provided on June 16, 2023. 
 
You asked the Plan to pay more for the dental services. You say that you would like to be reimbursed for what 
you paid. The Plan denied your request. The Plan says you are responsible for any charged amount above the 
Plans cost-sharing amount when your services are received from an out-of-network provider.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
You have been asked to pay the difference between the out-of-network providers charges and the Plans 
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to pay more for dental services provided on June 16, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Altru Dx UTI-ABR Molecular Test Panel provided on 
April 24, 2023, and billed with codes 87481, 87653, 87798, and 87801. 
 
You asked the Plan to pay for the Altru Dx UTI-ABR Molecular Test Panel. You say that this testing was 
medically necessary. The Plan denied your request. The Plan says this testing should be billed with a single 
panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that a panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. This test was not billed with a single panel code as required. Based 
on this information, we decided that Medicare rules for coverage of the Altru Dx UTI-ABR Molecular Test Panel have not been met. Therefore, we decided that the Plan does not have to pay for the Altru Dx UTI-ABR 
Molecular Test Panel provided on April 24, 2023, and billed with codes 87481, 87653, 87798, and 87801.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acupuncture services. 
 
You asked the Plan to pre-approve acupuncture services. You say that the enrollee has ongoing persistent 
chronic low back pain prior to 2020. The Plan denied your request. The Plan says that the requested provider is 
unqualified. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year.  We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the provider is not and was not supervised by a 
physician, physician assistant, or nurse practitioner/clinical nurse specialist. Therefore, we decided that the Plan 
does not have to pre-approve acupuncture services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve additional chiropractic treatments. 
 
You asked the Plan to pre-approve the chiropractic services. You say that without frequent and consistent 
treatment the enrollee's symptoms will get worse. The Plan denied your request. The Plan says that the criteria 
for coverage have not been met. 
 
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 has not provided documentation showing that the enrollees 
supplemental Health and Wellbeing benefit for routine chiropractic services has been exhausted. Therefore, we 
decided that the Plan has to pre-approve additional chiropractic treatments.  
 
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 pre-approve an all-white glass crown (D2740) for tooth number 3. 
 
You asked the Plan to pre-approve an all-white glass crown (D2740) for tooth number 3. You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says  the x-rays your dentist sent 
show your tooth does not have the damage needed for a crown to be needed to fix your tooth. 
 
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 an all-white 
glass crown (D2740) for tooth number 3 when the services are medically necessary and reasonable.  
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that the Plan's rules for 
coverage of an all-white glass crown (D2740) for tooth number 3 have not been met. Therefore, we decided 
that the Plan does not have to pre-approve an all-white glass crown (D2740) for tooth number 3.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the brain 
(70551), a magnetic resonance angiography (MRA) of the neck (70547) and a magnetic resonance angiography 
(MRA) of the head (70544). 
 
You asked the Plan to pre-approve an MRI of the brain (70551), a MRA of the neck (70547) and a MRA of the 
head. The Plan denied your request. The Plan says an MRI of the brain (70551), a MRA of the neck (70547) 
and a MRA of the head is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  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 an MRI of the brain (70551), a MRA of 
the neck (70547) and a MRA of the head. Our reviewer says that an MRI of the brain (70551), a MRA of the 
neck (70547) and a MRA of the head is not medically necessary. Our physician reviewer found that an MRI of 
the brain has already been performed with findings of cerebral atrophy and chronic microvascular disease. 
However, there are no new signs or symptoms to necessitate a repeat MRI of the brain. Additionally, an MRA 
is not considered medically reasonable and necessary for screening asymptomatic patients for intracranial 
aneurysms. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the brain (70551), a MRA of the neck (70547) and a MRA of the 
head have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic 
resonance imaging (MRI) of the brain (70551), a magnetic resonance angiography (MRA) of the neck (70547) 
and a magnetic resonance angiography (MRA) of the head (70544).
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on June 16, 2023. 
 
You asked the Plan to pay for physical therapy. 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 physical therapy 
provided on June 16, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the crown - porcelain/ceramic (D2740), and core buildup, 
including any pins when required (D2950) provided on July 19, 2023. 
 
You asked the Plan to pay for the dental services. You say that you have only been to the dentist 3 times and 
you don't understand how your benefits have been used. The Plan denied your request. The Plan says your 
benefit for the requested services $1,500 dollar limit was met 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
 Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the requested services was exhausted on dates of service June 30, 2023, and July 6, 
2023 and the dental allowance was applied to these claims. Therefore, we decided that the Plan does not have 
to pay for the crown - porcelain/ceramic (D2740), and core buildup, including any pins when required (D2950) 
provided on July 19, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance response and treatment with no transport 
provided on June 27, 2023. 
 
You asked the Plan to pay for ambulance response and treatment with no transport. You say that you were hit 
in the head with a baseball, but opted for your husband to bring you to the facility in Greece on the way back 
home. The Plan denied your request. The Plan says this service is not payable by this Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
  The ambulance company did not provide transport services on June 27, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance response and treatment with no 
transport provided on June 27, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional non-emergency transportation trips. 
 
You asked the Plan to pre-approve additional non-emergency transportation trips. You say that you are a cancer 
patient and are depending on taxi trips for which you cannot pay. The Plan denied your request. The Plan says 
this 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 32 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 non-emergency transportation trips.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for skilled nursing facility provided on March 
07, 2023, to March 23, 2023. 
 
You asked the Plan to waive the copayment for skilled nursing facility. You say that you contacted the Plan 
after receiving the bill and was told to disregard the bill. 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 $196 
copayment for Skilled Nursing Facility (SNF) Care.  
You have been asked to pay a $196 copayment for skilled nursing facility. This item/service falls within the 
Skilled Nursing Facility (SNF) 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. You have been asked to pay a total of $2,744 for the skilled nursing facility stay 
($196 copayment x 14 days = $2,744). Therefore, we decided that the Plan does not have to waive the 
copayment for skilled nursing facility provided on March 07, 2023, to March 23, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the dental services (D0330, D6010 and D6060). 
 
You asked the Plan to pre-approve the dental services (D0330, D6010 and D6060). You say that you would 
like to request reconsideration of the denied claim and that the services requested are medically necessary. The 
Plan denied your request. The Plan says your benefit for the requested dental services (D0330) has already 
been exhausted. The dental services (D6010 and D6060) are not covered 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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service October 2, 2023. Therefore, we decided that the Plan does not have to pre-approve the dental services (D0330, D6010 and 
D6060).
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance response and treatment with no transport 
provided on May 31, 2023. 
 
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the 
enrollee was seen with the ambulance staff and went to the emergency room with her son. You also say that if 
then enrollee went with the ambulance staff the copayment would have been $275 and now the ambulance 
service is charging $413.04 for the service. The Plan denied your request. The Plan says these services are not a 
covered benefit.  
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on May 31, 2023. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no 
transport provided on May 31, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Dexcom G7 continuous glucose monitor (CGM).  
You asked the Plan to pre-approve a CGM. You say that the enrollee needs this CGM. The Plan denied your 
request. The Plan says the medical criteria for a CGM has not been met, 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary when prescribed in accordance with their FDA indications for enrollees with diabetes 
who are insulin treated or who have a history of problematic hypoglycemia, and have had an in-person visit 
with their treating physician to evaluate their diabetes control and determine whether the criteria for coverage 
have been met. 
 
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin or 
have a history of problematic hypoglycemia. Based on this information, we decided that Medicare rules for 
coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
Dexcom G7 continuous glucose monitor (CGM).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional routine transportation trips (A0120). 
 
You asked the Plan to pre-approve the additional trips. You say that you need the additional trips because your 
health is in jeopardy. You also say that you will now have to re-schedule all your appointments since you have 
no transportation available. The Plan denied your request. The Plan says the record shows as of September 26,  
2023, you have used 71 trips.  
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 72 trips per year.  
 
We looked at your request, the records in the case file, and the rules. You asked the Plan to approve the 
additional trips for your 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 12 additional routine transportation trips (A0120).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the core buildup (D2950) for tooth #32. 
 You asked the Plan to pre-approve the dental service. You say that the dentist did not perform any work and it 
should be fraud. The Plan denied your request. The Plan says the denial of authorization for this service is 
correct, because the core buildup is not covered by the Plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Also, the case file shows that the services are an estimate and there are 
no dental services that have been billed. Therefore, we decided that the Plan does not have to pre-approve the 
core buildup (D2950) for tooth #32.  
 
Your complaint about your grievances with the provider 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 for the consultation (D9310) provided on July 31, 2023. 
 
You asked the Plan to pay for the dental services. You say that your provider asked you to come back the 
following day for a consult on your treatment plan. The Plan denied your request. The Plan says this service is 
not a covered benefit under your 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 the 
consultation (D9310) provided on July 31, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the mandibular partial denture - cast metal framework 
with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214). 
 
You asked the Plan to pre-approve the mandibular partial denture. You say that you accidentally threw away 
the partial lower denture that you previously received in March 2022. 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 March 4, 2022.  Therefore, we decided that the Plan does not have to pre-approve the mandibular partial denture - cast metal 
framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biologic materials to aid in soft and osseous tissue 
regeneration in conjunction with periradicular surgery (D3431). 
 
You asked the Plan to pre-approve the biologic materials. You say that your dentist told you that this service is 
necessary and if not covered by your health plan your out-of-pocket would be $650 which you cannot afford. 
You also say that you experienced pain previously but you are not currently experiencing any pain. The Plan 
denied your request. The Plan says this service is not covered under your benefit 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 service is not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve biologic 
materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery (D3431).