Persius/hicric huggingface dataset:
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 completion of inpatient acute rehab will help avert 
unplanned readmission to the acute care hospital and ensure a safe discharge home for the enrollee. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for admission to an IRF.  
 
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. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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 the periodontal scaling and root planing (D4341) for teeth #9 
to #16 provided on March 23, 2022. 
 
You asked the Plan to pay for the dental service. You say that the clinic recommended that you have cleanings 
every 6 months. 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 the Plan paid for the periodontal scaling and root planing (D4341) for teeth #9 to #16 on November 16, 
2020; therefore, your benefit for the requested item or service was exhausted on the date of service of 
November 16, 2020. Therefore, we decided that the Plan does not have to pay for the periodontal scaling and 
root planing (D4341) for teeth #9 to #16 provided on March 23, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for periodic evaluation (D0120) provided on March 29, 2023. 
 
You asked the Plan to pay for the dental services. You say that this should be covered. 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 June 15, 2022, and 
December 28, 2022. Therefore, we decided that the Plan does not have to pay for periodic evaluation (D0120) 
provided on March 29, 2023.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are medically necessary for 
the enrollee's medically complex needs. The Plan denied your request. The Plan says the enrollee's medical 
needs are being met in the current setting.  
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee does not require services at the LTACH that are not available at the acute 
care hospital where they are currently receiving care. All medically necessary care is being provided in the 
current acute care setting.  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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an implant maintenance procedure (D6080) provided on 
March 2, 2023. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered as you disagree 
with the denial. The Plan denied your request. The Plan says the services denied correctly as they do not fall 
within your dental benefits. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
 
  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an 
implant maintenance procedure (D6080) provided on March 2, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for bitewings (D0270), an intraorrifice barrier (D3911), and an 
unspecified endodontic procedure (D3999), provided on February 8, 2023. 
 
You asked the Plan to pay for D0270, D3911, and D3999. You say that you would like the Plan to reimburse 
you. The Plan denied your request. The Plan says the rendered services 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, 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 bitewings 
(D0270), an intraorrifice barrier (D3911), and an unspecified endodontic procedure (D3999), provided on 
February 8, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for eyeglasses purchased on March 1, 2022.  
 
You asked the Plan to pay for eyeglasses. You say that your mom received a booklet from the Plan indicating 
she would have an allowance toward eyeglasses. The Plan denied your request. The Plan says Plan guidelines 
say eyeglasses are covered after cataract surgery only. 
 
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 only right after cataract surgery. 
 
We looked at the file and the Plan's rules. The Plan rules also say that they cover one pair of eyeglasses after 
each cataract surgery that includes insertion of an intraocular lenses (additional pairs of eyeglasses are not 
covered by Medicare). Routine eyeglasses are not covered under this benefit. Based on this information, we 
decided that the Plan's rules for coverage of eyeglasses have not been met. Therefore, we decided that the Plan 
does not have to pay for eyeglasses purchased on March 1, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay more for a filling and palliative (emergency) treatment (D2393, 
D9110) provided on January 13, 2023, to January 17, 2023.  
 
You asked the Plan to pay more for the dental services. You say that the services should be covered as you 
disagree with the denial. 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 a filling and palliative (emergency) 
treatment (D2393, D9110) provided on January 13, 2023, to January 17, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the manual therapy (97140) and the office visit (99213) 
provided on January 26, 2023. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not a covered benefit.  
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
  
 
 
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the manual therapy (97140) and the office visit (99213) provided on 
January 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a maxillary interim partial denture (D5820) and application 
of caries arresting medicament - per tooth (D1354) provided February 14, 2023. 
 
You asked the Plan to pay for a maxillary interim partial denture (D5820) and application of caries arresting 
medicament - per tooth (D1354). You say that you are appealing with supporting records. The Plan denied your 
request. The Plan says codes D5820 and D1354 are not on the list of covered codes on the EOC. 
 
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 
maxillary interim partial denture (D5820) and application of caries arresting medicament - per tooth (D1354) 
provided February 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services provided on November 15, 2021, to January 
18, 2022. . 
 
You asked the Plan to pay for the dental services. You say that this should be covered. The Plan denied your 
request. The Plan says your $1,500 annual maximum 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. Therefore, we decided that the Plan does 
not have to pay for dental services provided on November 15, 2021, to January 18, 2022. .
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on January 11, 2023. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you complete 
a lung cancer screening each year and is covered at $0 copayment one time per year. 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 $150 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $150 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $135.87, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on January 11, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a panoramic radiographic image (D0330), comprehensive 
oral evaluation - new or established patient (D0150), and bitewings - four radiographic images (D0274) 
provided on March 13, 2023. 
 
You asked the Plan to pay for the panoramic radiographic image, comprehensive oral evaluation, and 
bitewings. You say that you verified with the Plan's customer service agent that this provider was in-network. 
The Plan denied your request. The Plan says the dental services were received from an out-of-network provider 
and are not covered by your supplemental benefits.  
 Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a panoramic radiographic image (D0330), comprehensive oral evaluation - new or established patient 
(D0150), and bitewings - four radiographic images (D0274) provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve frames (V2020), and progressive lens (V2781) provided 
on February 26, 2023. 
 
You asked the Plan to pre-approve frames (V2020), and progressive lens (V2781). You say that you are 
appealing with supporting records. The Plan denied your request. The Plan says your plan does not allow 
reimbursement for service(s) from a provider who is not a network provider. 
 
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 they are received by an in-network provider. 
 
We looked at the file and the Plan's rules. The Plan rules say that services will only be covered if they are 
provided by an in-network provider. The record shows that these services were received by an out-of-network 
provider. Based on this information, we decided that the Plan's rules for coverage of frames (V2020), and 
progressive lens (V2781) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
frames (V2020), and progressive lens (V2781) provided on February 26, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a periodic oral evaluation (D0120), the panoramic 
radiographic image (D0330), and a cleaning (D1110) provided by an out-of-network provider on April 26, 
2023. 
 
You asked the Plan to pay for the dental services. You say that the provider told you that they were an in-
network provider so the dental services should be covered. The Plan denied your request. The Plan says the 
dental services were received from an out-of-network provider and are not covered by your supplemental 
benefits.  
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a periodic oral evaluation (D0120), the panoramic radiographic image (D0330), and a cleaning 
(D1110) provided by an out-of-network provider on April 26, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes G2212 and 99205 billed for date of service 
February 24, 2023. 
 You asked the Plan to pay for the billed services. You say that the claim was billed correctly. The Plan denied 
your request. The Plan says an incorrect place of service was billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We find that CPT codes G2212 and 99205 were billed with place of service code 22. The information in the 
case file does not show that the services were provided in an on campus-outpatient hospital setting. Based on 
this information, we decided that Medicare rules for coverage of the billed services have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure codes G2212 and 99205 billed for date 
of service February 24, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited oral evaluation (D0140), bitewings (D0270), and a 
panoramic radiographic image (D0330) provided by an out-of-network provider on April 4, 2023. 
 
You asked the Plan to pay for the dental services. You say that the Plan provided you with provider names and 
you would like to appeal the denied dental services. The Plan denied your request. The Plan says the dental 
services were received from an out-of-network provider and are not covered by your supplemental benefits. 
Also, it was verified that you never contacted the Plan prior to the date of 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. 
 
  The record shows you received the requested dental services from an out-of-network provider. Though the Plan 
offers a dental benefit in excess of Medicare coverage, the requested items or services are not covered under 
this benefit when received from an out-of-network provider. Therefore, we decided that the Plan does not have 
to pay for a limited oral evaluation (D0140), bitewings (D0270), and a panoramic radiographic image (D0330) 
provided by an out-of-network provider on April 4, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse for a AAA auto membership purchased on January 31, 
2023. 
 
You asked the Plan to reimburse for a AAA auto membership. You say that this program is to help seniors 
when they run out of gas. You also say that you checked the coverage in the EOC, and it said AAA senior 
driving was there, so that is why you filed a reimbursement. The Plan denied your request. The Plan says that 
AAA Senior Driving is a separate membership from the AAA auto membership. The Plan also says that they 
cannot reimburse for the AAA membership. 
 
  The Plan must follow Medicare rules. Medicare rules say that a health education program may be offered as a 
supplemental benefit if it is offered to all enrollees or targeted to groups of enrollees based on a diagnosis of, or 
risk for, a specific disease condition and provides more than written material or a website and go beyond 
content alone to include interaction with an educator or professional.  
 
We looked at the file and Medicare rules. The record shows that your reimbursement request is for AAA auto 
membership. Triple AAA membership is a separate membership from the AAA senior driving. Based on this 
information, we decided that Medicare rules for coverage of a AAA auto membership have not been met. 
Therefore, we decided that the Plan does not have to reimburse for a AAA auto membership purchased on 
January 31, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for a PET scan provided on December 22, 2022. 
 
You asked the Plan to waive the cost share for a PET scan. You say that you were not advised of how 
expensive the test would be. 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 drugs and a $100 copayment for diagnostic radiology.  
 You have been asked to pay $1,792 for a PET scan. This total includes a $100 copayment for the PET scan and 
$1,692, which is 20% of the allowed amount for a Part B drug ($8,460 allowed x 20% = $1,692). The Part B 
drug falls within the Medicare Part B prescription drugs benefit category. The PET scan falls within the 
outpatient diagnostic tests benefit category. This means that you have been asked to pay the correct amount 
based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the cost share for a PET scan 
provided on December 22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan 
provided on August 18, 2022. 
 
You asked the Plan to waive the copayment for a computed tomography (CT) scan. You say that you thought 
the CT scan was fully covered and now you are receiving a 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 $175 
copayment for outpatient diagnostic test. 
 
You have been asked to pay a $175 copayment for a computed tomography (CT) scan. This item/service falls 
within the outpatient diagnostic test 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 $137.11, which is less than the standard copayment for a 
CT scan. Therefore, we decided that the Plan does not have to waive the copayment for a computed 
tomography (CT) scan provided on August 18, 2022.